Provider Demographics
NPI:1639817182
Name:RYAN S. DIEDERICH, MD PC
Entity Type:Organization
Organization Name:RYAN S. DIEDERICH, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DIEDERICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-7855
Mailing Address - Street 1:4955 S STATE ROUTE 159 # 1
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1907
Mailing Address - Country:US
Mailing Address - Phone:618-288-7855
Mailing Address - Fax:618-288-7866
Practice Address - Street 1:4955 S STATE ROUTE 159 # 1
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1907
Practice Address - Country:US
Practice Address - Phone:618-288-7855
Practice Address - Fax:618-288-7866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty