Basic Information
| Provider Information | |||||||||
| NPI: | 1083854574 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEITH A RYAN MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 E 15TH ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826094111 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1233 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075777201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2009 | ||||||||
| LastUpdateDate: | 05/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | RYAN | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED AGENT | ||||||||
| AuthorizedOfficialTelephone: | 3072354020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 7118A | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 120997300 | 05 | WY | MEDICAID | 313512 | 01 | WY | BLUE CROSS BLUE SHEILD OF WYOMING | OTHER |