Provider Demographics
NPI:1861424368
Name:RYERSON PODIATRY CENTER
Entity type:Organization
Organization Name:RYERSON PODIATRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:RYERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-237-3544
Mailing Address - Street 1:3048 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4704
Mailing Address - Country:US
Mailing Address - Phone:773-237-3544
Mailing Address - Fax:773-237-0902
Practice Address - Street 1:3048 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4704
Practice Address - Country:US
Practice Address - Phone:773-237-3544
Practice Address - Fax:773-237-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Not Answered213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL698180Medicare ID - Type Unspecified
ILT37972Medicare UPIN