Healthcare Provider Details

I. General information

NPI: 1326341645
Provider Name (Legal Business Name): KEVIN PATRICK RYAN MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W NORTH 12TH ST
SHELBYVILLE IL
62565-9554
US

IV. Provider business mailing address

420 KIRK DR
MT ZION IL
62549-1612
US

V. Phone/Fax

Practice location:
  • Phone: 217-774-2111
  • Fax: 217-774-9616
Mailing address:
  • Phone: 217-433-9595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: