Provider Demographics
NPI:1447251053
Name:RYAN, EDWARD (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:RYAN
Suffix:
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 1:16011 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8786
Mailing Address - Country:US
Mailing Address - Phone:708-364-0870
Mailing Address - Fax:708-364-0430
Practice Address - Street 1:16011 108TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-8786
Practice Address - Country:US
Practice Address - Phone:708-364-0870
Practice Address - Fax:708-364-0430
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049346208M00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036049346Medicaid
IL036049346Medicaid
ILL79489Medicare PIN
ILD93852Medicare UPIN