Healthcare Provider Details

I. General information

NPI: 1891766614
Provider Name (Legal Business Name): ELAINE ANN RYNDERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT ANTHONYS WAY SUITE 305
ALTON IL
62002-4569
US

IV. Provider business mailing address

2 SAINT ANTHONYS WAY
ALTON IL
62002-4569
US

V. Phone/Fax

Practice location:
  • Phone: 618-462-2222
  • Fax: 618-463-5004
Mailing address:
  • Phone: 618-465-8019
  • Fax: 618-463-5004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-000556
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: