Provider Demographics
NPI:1689872772
Name:MCDIVITT, RYAN LOUIS (PT, ATC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:LOUIS
Last Name:MCDIVITT
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:312-640-0407
Practice Address - Street 1:10940 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7980
Practice Address - Country:US
Practice Address - Phone:317-808-7000
Practice Address - Fax:317-808-7001
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009023A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201002710Medicaid
M400029836Medicare PIN