Provider Demographics
NPI:1164510418
Name:RYAN, MICHAEL TIMOTHY (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:RYAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S FLORIDA AVE STE 620
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5269
Mailing Address - Country:US
Mailing Address - Phone:863-688-1800
Mailing Address - Fax:863-688-1824
Practice Address - Street 1:500 S FLORIDA AVE STE 620
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5269
Practice Address - Country:US
Practice Address - Phone:863-688-1800
Practice Address - Fax:863-688-1824
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00088453OtherRR MCR #
FLPT17770OtherPT STATE LICENSE #
FLY7549OtherBCBS #
FL611414091OtherTAX ID
FL113534600Medicaid