Provider Demographics
NPI:1285096792
Name:KING, NATHAN RYAN (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:RYAN
Last Name:KING
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 1:820 S WOOD ST # MC808
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:123-996-7006
Mailing Address - Fax:
Practice Address - Street 1:1801 W TAYLOR ST # MC650
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-413-7500
Practice Address - Fax:312-413-3856
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125068647207VG0400X
390200000X
IL036160222207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program