Provider Demographics
NPI:1578575809
Name:RUZIC, SAMUEL W (PT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:W
Last Name:RUZIC
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 1:1255 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-4001
Mailing Address - Country:US
Mailing Address - Phone:815-547-4733
Mailing Address - Fax:815-547-9733
Practice Address - Street 1:1255 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-4001
Practice Address - Country:US
Practice Address - Phone:815-547-4733
Practice Address - Fax:815-547-9733
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-000626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-012135OtherPROFESSIONAL LICENSE
IL070-012135OtherPROFESSIONAL LICENSE
L93894Medicare ID - Type Unspecified