Provider Demographics
NPI:1093717480
Name:HENNESSY, RYON MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:RYON
Middle Name:MICHAEL
Last Name:HENNESSY
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 1:360 W BUTTERFIELD RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5068
Mailing Address - Country:US
Mailing Address - Phone:630-782-9600
Mailing Address - Fax:630-782-1643
Practice Address - Street 1:360 W BUTTERFIELD RD
Practice Address - Street 2:SUITE 160
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5068
Practice Address - Country:US
Practice Address - Phone:630-782-9600
Practice Address - Fax:630-782-1643
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-093298207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02222323OtherBCBS
IL036093298Medicaid
IL200028061OtherMEDICARE RAILROAD
IL200028061OtherMEDICARE RAILROAD
IL036093298Medicaid
G51219Medicare UPIN
IL0139440002Medicare NSC
ILK53251Medicare PIN