Healthcare Provider Details

I. General information

NPI: 1225538010
Provider Name (Legal Business Name): VIOLET RUZICKA SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2018
Last Update Date: 02/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6529 26TH PL
BERWYN IL
60402-4701
US

IV. Provider business mailing address

6529 26TH PL
BERWYN IL
60402-4701
US

V. Phone/Fax

Practice location:
  • Phone: 708-603-1431
  • Fax:
Mailing address:
  • Phone: 708-603-1431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number17-694
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: