Provider Demographics
NPI:1114957933
Name:FLIPSE, RYAN (PT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:FLIPSE
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 1:10388 REDWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9502
Mailing Address - Country:US
Mailing Address - Phone:219-365-0742
Mailing Address - Fax:
Practice Address - Street 1:12937 WICKER AVE
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-9343
Practice Address - Country:US
Practice Address - Phone:219-979-2734
Practice Address - Fax:219-924-4978
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007929A225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN199620AMedicare PIN
IN252510AMedicare PIN
ILP00226243Medicare PIN
ILK11497Medicare PIN