Provider Demographics
NPI:1659690022
Name:SUBURBAN METABOLIC INSTITUTE, LLC
Entity Type:Organization
Organization Name:SUBURBAN METABOLIC INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HEADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-484-0621
Mailing Address - Street 1:3245 GROVE AVE
Mailing Address - Street 2:STE. 202
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3474
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
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUBURBAN SURGICAL ASSOCIATES, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-25
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114720174400000X
IL036118355174400000X
261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03611470Medicaid
ILI55287Medicare UPIN