Healthcare Provider Details

I. General information

NPI: 1104989409
Provider Name (Legal Business Name): ZORIAN P TRUSEWYCH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 N 12TH ST BLDG 29M
QUINCY IL
62301
US

IV. Provider business mailing address

1707 N 12TH ST BLDG 29M
QUINCY IL
62301
US

V. Phone/Fax

Practice location:
  • Phone: 217-222-8641
  • Fax: 217-222-8578
Mailing address:
  • Phone: 217-222-9487
  • Fax: 217-222-8578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036077602
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036-077602
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: