Provider Demographics
NPI:1205199502
Name:PRUS, IGOR (MD)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:PRUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 W FOSTER AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3547
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-298-8804
Practice Address - Street 1:5215 N CALIFORNIA AVE STE 804
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7014
Practice Address - Country:US
Practice Address - Phone:773-907-7750
Practice Address - Fax:773-907-7760
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.136049207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILRES000Medicare UPIN