1962480798 NPI number — DR. ARON BRUK M.D.

Table of content: DR. ARON BRUK M.D. (NPI 1962480798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962480798 NPI number — DR. ARON BRUK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUK
Provider First Name:
ARON
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962480798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 126
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62298-0126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-939-8190
Provider Business Mailing Address Fax Number:
618-939-3990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 BRADFORD LN
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62298-3267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-939-8190
Provider Business Practice Location Address Fax Number:
618-939-3990
Provider Enumeration Date:
01/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)