Provider Demographics
NPI:1235491697
Name:SMITH, RYAN MICHEAL (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MICHEAL
Last Name:SMITH
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 1:1611 W HARRISON ST STE 550
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:312-942-6100
Mailing Address - Fax:312-942-6225
Practice Address - Street 1:1611 W HARRISON ST STE 550
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-942-6100
Practice Address - Fax:312-942-6225
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-146879207Y00000X, 207YX0905X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery