Provider Demographics
NPI:1073390571
Name:LIN, JOHN RYAN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RYAN
Last Name:LIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19642
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9642
Mailing Address - Country:US
Mailing Address - Phone:217-545-8229
Mailing Address - Fax:
Practice Address - Street 1:319 E MADISON ST FL 3
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1035
Practice Address - Country:US
Practice Address - Phone:217-545-8229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2024-06-20
Deactivation Date:2024-05-23
Deactivation Code:
Reactivation Date:2024-06-05
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.0842282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program