Healthcare Provider Details

I. General information

NPI: 1205199502
Provider Name (Legal Business Name): IGOR PRUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 N CALIFORNIA AVE STE 804
CHICAGO IL
60625-7014
US

IV. Provider business mailing address

2740 W FOSTER AVE STE 310
CHICAGO IL
60625-3547
US

V. Phone/Fax

Practice location:
  • Phone: 773-907-7750
  • Fax: 773-907-7760
Mailing address:
  • Phone: 773-878-8200
  • Fax: 773-298-8804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.136049
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036.136049
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: