=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396836540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEI WOO RYOO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 S. DAMEN AVE PATH & LAB MEDICINE SERVICE (MP 113)
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-569-6696
-----------------------------------------------------
Fax | 312-569-6122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1816 DUNHILL CIR
-----------------------------------------------------
City | GLENVIEW
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60025-7618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-486-9488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------