Basic Information
Provider Information | |||||||||
NPI: | 1477588499 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JENNINGS | ||||||||
FirstName: | RYAN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1268 | ||||||||
Address2: |   | ||||||||
City: | EFFINGHAM | ||||||||
State: | IL | ||||||||
PostalCode: | 624011268 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2173424151 | ||||||||
FaxNumber: | 2173424133 | ||||||||
Practice Location | |||||||||
Address1: | 200 HEALTH CARE DR | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622461154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186641230 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 05/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036103305 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | 036103305 | IL | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208M00000X | 036103305 | IL | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 076042 | 01 | IL | HEALTH ALLIANCE # | OTHER | 0460911 | 01 | IL | HEALTHLINK # | OTHER | 036103305 | 05 | IL |   | MEDICAID | 2523659 | 01 | IL | BC/BS # | OTHER | 110232704 | 01 | IL | RAILROAD MEDICARE/PALMETTO GBA | OTHER |