Provider Demographics
NPI:1477588499
Name:JENNINGS, RYAN L (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:L
Last Name:JENNINGS
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:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-1268
Mailing Address - Country:US
Mailing Address - Phone:217-342-4151
Mailing Address - Fax:217-342-4133
Practice Address - Street 1:200 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1154
Practice Address - Country:US
Practice Address - Phone:618-664-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103305207R00000X, 208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL076042OtherHEALTH ALLIANCE #
IL0460911OtherHEALTHLINK #
IL036103305Medicaid
IL2523659OtherBC/BS #
IL110232704OtherRAILROAD MEDICARE/PALMETTO GBA
IL2523659OtherBC/BS #
IL347560Medicare PIN