Provider Demographics
NPI:1013925718
Name:RYAN, RAYMOND J JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:J
Last Name:RYAN
Suffix:JR
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 1:200 HEALTHCARE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246
Mailing Address - Country:US
Mailing Address - Phone:618-664-6966
Mailing Address - Fax:618-664-6971
Practice Address - Street 1:200 HEALTHCARE DRIVE
Practice Address - Street 2:STE 1559
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246
Practice Address - Country:US
Practice Address - Phone:618-664-6966
Practice Address - Fax:618-664-6971
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091276174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG16025Medicare UPIN