Provider Demographics
NPI:1629029210
Name:ACKERMANN, RONALD (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:ACKERMANN
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 1:675 N SAINT CLAIR ST
Mailing Address - Street 2:STE. 18-200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5975
Mailing Address - Country:US
Mailing Address - Phone:312-695-8630
Mailing Address - Fax:312-695-2857
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:STE. 18-200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-8630
Practice Address - Fax:312-695-2857
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129127207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200459950Medicaid
IN000000314314OtherANTHEM
INH21332Medicare UPIN
IN200459950Medicaid