Provider Demographics
NPI:1215176078
Name:AVERY, RYAN J (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:AVERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 800
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2978
Mailing Address - Country:US
Mailing Address - Phone:312-695-5753
Mailing Address - Fax:312-695-5645
Practice Address - Street 1:676 N SAINT CLAIR ST STE 800
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-695-5753
Practice Address - Fax:312-695-5645
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ45120207U00000X, 2085N0904X, 2085R0202X
IL036.1468302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology