Provider Demographics
NPI:1518049204
Name:DOUGLAS A KRUSE MD LLC
Entity Type:Organization
Organization Name:DOUGLAS A KRUSE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:KRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-526-2222
Mailing Address - Street 1:9495 HOLY CROSS LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-3510
Mailing Address - Country:US
Mailing Address - Phone:618-526-2222
Mailing Address - Fax:618-526-7680
Practice Address - Street 1:9495 HOLY CROSS LN
Practice Address - Street 2:SUITE 103
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-3510
Practice Address - Country:US
Practice Address - Phone:618-526-2222
Practice Address - Fax:618-526-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098255Medicaid
ILIL BLUESHIELDOther01427671
ILIL BLUESHIELDOther01427671
IL706180Medicare PIN