Provider Demographics
NPI:1710156369
Name:MARK RYERSON
Entity Type:Organization
Organization Name:MARK RYERSON
Other - Org Name:CENTRAL PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:RYERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-255-0330
Mailing Address - Street 1:125 E CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2649
Mailing Address - Country:US
Mailing Address - Phone:847-255-0330
Mailing Address - Fax:847-255-1785
Practice Address - Street 1:125 E CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2649
Practice Address - Country:US
Practice Address - Phone:847-255-0330
Practice Address - Fax:847-255-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003397213E00000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207820Medicare PIN
ILT37972Medicare UPIN
IL4489540001Medicare NSC