Provider Demographics
NPI:1558646745
Name:BRUSCA, PETER ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ANTHONY
Last Name:BRUSCA
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 1:1310 N RITCHIE CT
Mailing Address - Street 2:29B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2168
Mailing Address - Country:US
Mailing Address - Phone:239-776-5059
Mailing Address - Fax:
Practice Address - Street 1:1310 N RITCHIE CT
Practice Address - Street 2:29B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2168
Practice Address - Country:US
Practice Address - Phone:239-776-5059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036043341207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck