MEDICARE: JOY A DERUSHA PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	10000869A	IN
2	363A00000X	Physician Assistant	085.002734	IL

General Provider Information

NPI Number	:	1396940375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOY A DERUSHA PA

Provider Business Mailing Address
First Line	:	1029 EAST 130TH STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-4039
Country	:	US
Telephone Number	:	773-995-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1029 EAST 130TH STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-4039
Country	:	US
Telephone Number	:	773-387-2519
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2007
Last Update Date	:	06/05/2015

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