Provider Demographics
NPI:1043273915
Name:JERCINOVIC, BRUNO JOHN (MD)
Entity Type:Individual
Prefix:MR
First Name:BRUNO
Middle Name:JOHN
Last Name:JERCINOVIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-3772
Mailing Address - Country:US
Mailing Address - Phone:815-729-1144
Mailing Address - Fax:815-729-2587
Practice Address - Street 1:611 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-3772
Practice Address - Country:US
Practice Address - Phone:815-729-1144
Practice Address - Fax:815-729-2587
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069711208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC47678Medicare UPIN