Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 12010606A | IN |
Y | 213EG0000X | General Practice | 12010606A | IN |
NPI | 1003861287 |
---|---|
Provider Name | Ryan Campbell Jay |
First Address | Indianapolis, IN 46236 |
Second Address | Indianapolis, IN 46236 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2006 |
Last Update Date | 02/03/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100071480A | (05) | IN |
200460270A | (05) | IN |