Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036.136049 | IL |
Y | 207QS0010X | Family Doctor - Sports Medicine | 036.136049 | IL |
NPI | 1205199502 |
---|---|
Provider Name | Igor Prus |
First Address | Chicago, IL 60625-3547 |
Second Address | Chicago, IL 60625-7014 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2012 |
Last Update Date | 07/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RES000 | (02) | IL |