Healthcare Provider Details

I. General information

NPI: 1356395875
Provider Name (Legal Business Name): MARK RYERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E CENTRAL RD
ARLINGTON HTS IL
60005-2649
US

IV. Provider business mailing address

125 E CENTRAL RD
ARLINGTON HTS 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 TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016003397
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number016003397
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number016003397
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: