Provider Demographics
NPI:1447388657
Name:PRUS, JAROSLAW (PT)
Entity Type:Individual
Prefix:MR
First Name:JAROSLAW
Middle Name:
Last Name:PRUS
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 1:6444 WEST BELMONT AVENUE
Mailing Address - Street 2:UNIT B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634
Mailing Address - Country:US
Mailing Address - Phone:773-283-7535
Mailing Address - Fax:773-283-7530
Practice Address - Street 1:6444 WEST BELMONT AVENUE
Practice Address - Street 2:UNIT B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634
Practice Address - Country:US
Practice Address - Phone:773-283-7535
Practice Address - Fax:773-283-7530
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.012652225100000X
IL070-012652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist