Basic Information
| Provider Information | |||||||||
| NPI: | 1639817182 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RYAN S. DIEDERICH, MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4955 S STATE ROUTE 159 # 1 | ||||||||
| Address2: | |||||||||
| City: | GLEN CARBON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620341907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182887855 | ||||||||
| FaxNumber: | 6182887866 | ||||||||
| Practice Location | |||||||||
| Address1: | 4955 S STATE ROUTE 159 # 1 | ||||||||
| Address2: | |||||||||
| City: | GLEN CARBON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620341907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182887855 | ||||||||
| FaxNumber: | 6182887866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | DIEDERICH | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6182887855 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No ID Information.