Provider Demographics
NPI:1417062829
Name:BRUESCHKE, TINA M (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:M
Last Name:BRUESCHKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2363 63RD ST
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1369
Mailing Address - Country:US
Mailing Address - Phone:630-716-7510
Mailing Address - Fax:
Practice Address - Street 1:2363 63RD ST
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1369
Practice Address - Country:US
Practice Address - Phone:630-716-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36115136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05300288Medicaid
IL400480OtherGROUP MEDICARE PTAN
IL05300288Medicaid