Provider Demographics
NPI:1326341645
Name:RYAN, KEVIN PATRICK (MPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:RYAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 KIRK DR
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1612
Mailing Address - Country:US
Mailing Address - Phone:217-433-9595
Mailing Address - Fax:
Practice Address - Street 1:1111 W NORTH 12TH ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-9554
Practice Address - Country:US
Practice Address - Phone:217-774-2111
Practice Address - Fax:217-774-9616
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070017064OtherPT LICENSE