MEDICARE: MRS. GERMAINE A DESRUISSEAUX NP

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	363LF0000X	Family Nurse Practitioner	209006672	IL

General Provider Information

NPI Number	:	1578752051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GERMAINE A DESRUISSEAUX NP

Provider Business Mailing Address
First Line	:	161 WASHINGTON ST FL 14
Second Line	:	EIGHT TOWER BRIDGE, SUITE 1400
City	:	CONSHOHOCKEN
State	:	PA
Zip	:	19428-2083
Country	:	US
Telephone Number	:	484-351-3206
Fax Number	:

Provider Business Practice Location Address
First Line	:	1228 E 53RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4008
Country	:	US
Telephone Number	:	773-752-1425
Fax Number	:

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

Provider Enumeration Date	:	10/19/2007
Last Update Date	:	10/17/2017

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