Provider Demographics
NPI:1295982916
Name:BOLTON, RYAN J (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:BOLTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1801 W TAYLOR ST
Mailing Address - Street 2:3AA
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4795
Mailing Address - Country:US
Mailing Address - Phone:312-413-3627
Mailing Address - Fax:312-355-0212
Practice Address - Street 1:1801 W TAYLOR ST
Practice Address - Street 2:3AA
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-413-3627
Practice Address - Fax:312-355-0212
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2012-11-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN51863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110013046Medicare PIN