Provider Demographics
NPI:1942422498
Name:DIEDERICH, RYAN (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DIEDERICH
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 1:4955 S STATE ROUTE 159 STE 1
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1907
Mailing Address - Country:US
Mailing Address - Phone:618-288-7855
Mailing Address - Fax:618-288-7866
Practice Address - Street 1:4955 S STATE ROUTE 159 STE 1
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1907
Practice Address - Country:US
Practice Address - Phone:618-288-7855
Practice Address - Fax:618-288-7866
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-0502032086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery