Provider Demographics
NPI:1912163650
Name:RYDBERG, LESLIE K (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:K
Last Name:RYDBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 E ERIE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3167
Mailing Address - Country:US
Mailing Address - Phone:312-238-1000
Mailing Address - Fax:
Practice Address - Street 1:355 E ERIE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3167
Practice Address - Country:US
Practice Address - Phone:312-238-1000
Practice Address - Fax:312-238-5846
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125048924208100000X
IL036-122478208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036122478-1Medicaid
IL036122478-2Medicaid
IL572710006Medicare PIN
IL573230007Medicare PIN
IL806510003Medicare PIN