Provider Demographics
NPI:1184819815
Name:STOVER, RYAN (PT, MPT, CSCS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:STOVER
Suffix:
Gender:M
Credentials:PT, MPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1555 BARCLAY BLVD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-4518
Practice Address - Country:US
Practice Address - Phone:708-671-0771
Practice Address - Fax:708-671-0771
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7454077OtherAETNA
01622333OtherBLUE CROSS BLUE SHIELD ID