Healthcare Provider Details

I. General information

NPI: 1659355105
Provider Name (Legal Business Name): JO-ELLYN M. RYALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 S NEW BALLAS RD SUITE 110
SAINT LOUIS MO
63141-8704
US

IV. Provider business mailing address

5000 CEDAR PLAZA PKWY SUITE 350
SAINT LOUIS MO
63128-3854
US

V. Phone/Fax

Practice location:
  • Phone: 314-569-1717
  • Fax: 314-569-0441
Mailing address:
  • Phone: 314-843-4333
  • Fax: 314-843-4856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR7151
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: