Provider Demographics
NPI:1083761001
Name:KRUEGER, BRYAN (PT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6072 ROSEBUD RD
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-4119
Mailing Address - Country:US
Mailing Address - Phone:618-524-1038
Mailing Address - Fax:
Practice Address - Street 1:6072 ROSEBUD RD
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-4119
Practice Address - Country:US
Practice Address - Phone:618-524-1038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT-003999225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist