Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 016002661 | IL |
NPI | 1114978574 |
---|---|
Provider Name | John L Ruskusky |
First Address | Pekin, IL 61554-6237 |
Second Address | Pekin, IL 61554-6237 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2006 |
Last Update Date | 09/11/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T35879 | (02) | IL |