Provider Demographics
NPI:1437195567
Name:JORGENSON, RYAN JAMES (DPM)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JAMES
Last Name:JORGENSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5689 YORKTOWN TRCE
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-7428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PREFERRED PODIATRY GROUP
Practice Address - Street 2:425 HUEHL ROAD #13
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062
Practice Address - Country:US
Practice Address - Phone:847-504-5000
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001010A213E00000X
WI884-25213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0732240001OtherDMERC # WITH PPG
IN200844950AMedicaid
IN200844950AMedicaid
IN859800XMedicare PIN
INV01208Medicare UPIN
WI864920024Medicare PIN
WI814350021Medicare PIN