Healthcare Provider Details

I. General information

NPI: 1619612264
Provider Name (Legal Business Name): ADAM BRUINIUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

9534 S SPAULDING AVE
EVERGREEN PARK IL
60805-2242
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone: 708-717-1621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.025456
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: