=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982761144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSKUSKY FOOT AND ANKLE CLINIC, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 07/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3305 GRIFFIN AVE
-----------------------------------------------------
City | PEKIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61554-6237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-347-3886
-----------------------------------------------------
Fax | 309-347-4002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3305 GRIFFIN AVE
-----------------------------------------------------
City | PEKIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61554-6237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-347-3886
-----------------------------------------------------
Fax | 309-347-4002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY R RUSKUSKY
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 309-347-3886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 060008112
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------