Ryan Diederich, MD

Primary specialty

Plastic and Reconstructive Surgery PhysicianTaxonomy code 2086S0122X

License

125-050203 Issued in IL

Practice address

4955 S State Route 159 Ste 1
Glen Carbon, IL 62034-1907

Phone

(618) 288-7855

Fax

(618) 288-7866

NPI assigned

May 3, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178150400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1724198400000",
    "number": "1942422498",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4955 S STATE ROUTE 159 STE 1",
            "city": "GLEN CARBON",
            "state": "IL",
            "postal_code": "620341907",
            "telephone_number": "618-288-7855",
            "fax_number": "618-288-7866"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4955 S STATE ROUTE 159 STE 1",
            "city": "GLEN CARBON",
            "state": "IL",
            "postal_code": "620341907",
            "telephone_number": "618-288-7855",
            "fax_number": "618-288-7866"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DIEDERICH",
        "first_name": "RYAN",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-05-03",
        "last_updated": "2024-08-21",
        "certification_date": "2024-08-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2086S0122X",
            "taxonomy_group": "",
            "desc": "Surgery, Plastic and Reconstructive Surgery",
            "state": "IL",
            "license": "125-050203",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Tracee Depriest
• Tasha Dersch
• Brooke Brianne Deters, DMD
• Randi Deyong
• Lizbeth Hoepli Didriksen, M.D.
• Dennis Dietzen
• Samuel Lee Donavon, DMD
• Dover Hospice Il STL Metro, LLC
• Sara Downey, MSW, LCSW
• Dr. Mary Mioux-Berry, LLC

• Plastic and Reconstructive Surgery Physician in Glen Carbon, IL
• Providers in Glen Carbon, IL by specialty
• Plastic and Reconstructive Surgery Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 21, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.