Provider Demographics
NPI:1548257322
Name:RYAN, MARSHA G (MD)
Entity type:Individual
Prefix:
First Name:MARSHA
Middle Name:G
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-529-0568
Practice Address - Street 1:1237 E MAIN ST
Practice Address - Street 2:STE C1
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3148
Practice Address - Country:US
Practice Address - Phone:618-457-2281
Practice Address - Fax:618-529-0573
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036061951208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061951Medicaid
ILL61654Medicare ID - Type Unspecified
IL036061951Medicaid