Healthcare Provider Details

I. General information

NPI: 1558646745
Provider Name (Legal Business Name): PETER ANTHONY BRUSCA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 N RITCHIE CT 29B
CHICAGO IL
60610-2168
US

IV. Provider business mailing address

1310 N RITCHIE CT 29B
CHICAGO IL
60610-2168
US

V. Phone/Fax

Practice location:
  • Phone: 239-776-5059
  • Fax:
Mailing address:
  • Phone: 239-776-5059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number036043341
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: