Basic Information
| Provider Information | |||||||||
| NPI: | 1740895218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TWILLEY | ||||||||
| FirstName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 E HURON ST STE 5-704 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126950061 | ||||||||
| FaxNumber: | 3126959013 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 E HURON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129262000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2020 | ||||||||
| LastUpdateDate: | 01/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041.495018 | IL | N | Nursing Service Providers | Registered Nurse | 367500000X | 209021996 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.