Provider Demographics
NPI:1285625301
Name:MCCONNELL, RYAN P (DO)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:P
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:601 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9383
Mailing Address - Country:US
Mailing Address - Phone:231-536-2206
Mailing Address - Fax:231-536-9864
Practice Address - Street 1:601 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9383
Practice Address - Country:US
Practice Address - Phone:231-536-2206
Practice Address - Fax:231-536-9864
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4765816Medicaid
MIP00251496OtherRAILROAD MEDICARE
MIA56344019Medicare ID - Type Unspecified
MIH56478Medicare UPIN