MEDICARE: BRYAN M KRUSKOL DO

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	207V00000X	Obstetrics & Gynecology Physician	036102450	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	01932073	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1497739569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN M KRUSKOL DO

Provider Business Mailing Address
First Line	:	1850 GATEWAY DR STE 201
Second Line	:
City	:	SYCAMORE
State	:	IL
Zip	:	60178-3192
Country	:	US
Telephone Number	:	815-766-7021
Fax Number	:	815-758-5690

Provider Business Practice Location Address
First Line	:	1850 GATEWAY DR STE 201
Second Line	:
City	:	SYCAMORE
State	:	IL
Zip	:	60178-3192
Country	:	US
Telephone Number	:	815-766-7021
Fax Number	:	815-758-5690

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	06/06/2024

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Directions to “ BRYAN M KRUSKOL DO” Practice Location

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