Provider Demographics
NPI:1689664815
Name:RYAN, KARA RENEE (MD)
Entity type:Individual
Prefix:
First Name:KARA
Middle Name:RENEE
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:695 TRUMAN PKWY
Practice Address - Street 2:HYDE PARK PEDIATRICS
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3552
Practice Address - Country:US
Practice Address - Phone:617-361-1470
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220566208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA469350OtherTUFTS HEALTH PLAN
MA2063531Medicaid
MAJ27445OtherBCBS MA
MAA37009Medicare ID - Type Unspecified
MA469350OtherTUFTS HEALTH PLAN