Provider Demographics
NPI:1548847015
Name:SISSON-SMITH, RYAN (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SISSON-SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:CHRISTOPHER
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2528 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-4244
Mailing Address - Country:US
Mailing Address - Phone:765-860-6383
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:130-965-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036170233208000000X, 207R00000X
IL390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program