Provider Demographics
NPI:1285890640
Name:FUELLEMAN, RYAN THOMAS (BS DC)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:THOMAS
Last Name:FUELLEMAN
Suffix:
Gender:M
Credentials:BS DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4353 W SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-8487
Mailing Address - Country:US
Mailing Address - Phone:608-312-7825
Mailing Address - Fax:
Practice Address - Street 1:1831 W COURT ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3406
Practice Address - Country:US
Practice Address - Phone:608-312-7825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4663-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100014477Medicaid
WI100014477Medicaid