Healthcare Provider Details

I. General information

NPI: 1659646750
Provider Name (Legal Business Name): RYAN M DHAEMERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 800
CHICAGO IL
60611-2978
US

IV. Provider business mailing address

12530 TROPHY DR
FISHERS IN
46038-3075
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-5753
  • Fax: 312-695-5645
Mailing address:
  • Phone: 219-508-0248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01073867A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01073867A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036142488
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: