Provider Demographics
NPI:1346864493
Name:KELLY, RYAN MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MATTHEW
Last Name:KELLY
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 1:1725 W HARRISON ST STE 855
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-5113
Mailing Address - Country:US
Mailing Address - Phone:312-942-6644
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 855
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-5113
Practice Address - Country:US
Practice Address - Phone:312-942-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125076112207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery