Basic Information
| Provider Information | |||||||||
| NPI: | 1548257322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | MARSHA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1105 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
| FaxNumber: | 6185290568 | ||||||||
| Practice Location | |||||||||
| Address1: | 1237 E MAIN ST | ||||||||
| Address2: | STE C1 | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184572281 | ||||||||
| FaxNumber: | 6185290573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 12/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036061951 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036061951 | 05 | IL | MEDICAID |