Provider Demographics
NPI:1659309375
Name:HEADLEY, RYAN C (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:C
Last Name:HEADLEY
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 1:3340 S. OAK PARK AVE.
Mailing Address - Street 2:STE. 309
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3483
Mailing Address - Country:US
Mailing Address - Phone:708-484-0621
Mailing Address - Fax:708-484-0250
Practice Address - Street 1:908 N ELM ST STE 309
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3625
Practice Address - Country:US
Practice Address - Phone:708-484-0621
Practice Address - Fax:708-484-0250
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114720208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114720OtherLICENSE NUMBER
1659309375OtherNPI
IL517410Medicare PIN
IL212474Medicare PIN
ILBH9651414OtherFEDERAL DEA
ILK28800Medicare PIN