Provider Demographics
NPI:1437174885
Name:LAMPE, RYAN DEREK (PT/ATC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DEREK
Last Name:LAMPE
Suffix:
Gender:M
Credentials:PT/ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:618-651-0444
Mailing Address - Fax:618-654-5439
Practice Address - Street 1:560 N 2ND ST
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-1650
Practice Address - Country:US
Practice Address - Phone:618-526-7801
Practice Address - Fax:618-526-7901
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL453140OtherHEALTHLINK
ILP00248157OtherRR MEDICARE
IL453140OtherHEALTHLINK