MEDICARE: DR. EDWARD BAXTER RUSIN PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5672007	OTHER	IL	BC BS

General Provider Information

NPI Number	:	1235278342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD BAXTER RUSIN PHD

Provider Business Mailing Address
First Line	:	7009 CRYSTAL SPRINGS ROAD
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60012-1154
Country	:	US
Telephone Number	:	815-455-7333
Fax Number	:	815-477-0821

Provider Business Practice Location Address
First Line	:	7009 CRYSTAL SPRINGS ROAD
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60012-1154
Country	:	US
Telephone Number	:	815-455-7333
Fax Number	:	815-477-0821

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/08/2007

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