Healthcare Provider Details

I. General information

NPI: 1548257322
Provider Name (Legal Business Name): MARSHA G RYAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1237 E MAIN ST STE C1
CARBONDALE IL
62901-3148
US

IV. Provider business mailing address

PO BOX 1105
INDIANAPOLIS IN
46206-1105
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-2281
  • Fax: 618-529-0573
Mailing address:
  • Phone: 618-549-5361
  • Fax: 618-529-0568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036061951
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: