Basic Information
| Provider Information | |||||||||
| NPI: | 1033503412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDOVICH | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 29TH AVE N STE 201 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 29TH AVE N STE 201 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2015 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 66336 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208D00000X | 66336-20 | WI | N | Allopathic & Osteopathic Physicians | General Practice | 207L00000X | 63020 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1033503412 | 05 | WI | MEDICAID |