Provider Demographics
NPI:1356395875
Name:RYERSON, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RYERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HTS
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 HTS
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003397213E00000X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37972Medicare UPIN
IL4489540001Medicare PIN
IL207820Medicare PIN