Provider Demographics
NPI:1730210089
Name:CALDWELL, RYAN BLAINE (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:BLAINE
Last Name:CALDWELL
Suffix:
Gender:M
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 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-863-6241
Mailing Address - Fax:704-355-5948
Practice Address - Street 1:8800 NORTH TRYON STREET
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3300
Practice Address - Country:US
Practice Address - Phone:704-863-6241
Practice Address - Fax:704-355-5948
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29018207R00000X
NC2009-01380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1730210089Medicaid
NC5912204Medicaid
SCN0138AMedicaid
NC2074016Medicare PIN
SCN0138AMedicaid