Basic Information
| Provider Information | |||||||||
| NPI: | 1235392523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORLEY | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JACKSON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 535432 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303536220 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 927 EAST BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543840175 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2008 | ||||||||
| LastUpdateDate: | 07/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 66585 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | 2012-00769 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
No ID Information.