Provider Demographics
NPI:1487017257
Name:DYESS, RYAN JOHN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JOHN
Last Name:DYESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:RYAN
Other - Last Name:DYESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE A320
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6336
Practice Address - Country:US
Practice Address - Phone:864-454-5100
Practice Address - Fax:864-241-9238
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC885712080P0205X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid