Healthcare Provider Details

I. General information

NPI: 1710156369
Provider Name (Legal Business Name): MARK RYERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E CENTRAL RD
ARLINGTON HEIGHTS IL
60005-2649
US

IV. Provider business mailing address

125 E CENTRAL RD
ARLINGTON HEIGHTS IL
60005-2649
US

V. Phone/Fax

Practice location:
  • Phone: 847-255-0330
  • Fax: 847-255-1785
Mailing address:
  • Phone: 847-255-0330
  • Fax: 847-255-1785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016003397
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number016003397
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016003397
License Number StateIL

VIII. Authorized Official

Name: DR. MARK A RYERSON
Title or Position: OWNER
Credential: D.P.M.
Phone: 847-255-0330