Provider Demographics
NPI:1629101324
Name:DR. ANTHONY J. SURRUSCO, P.C.
Entity Type:Organization
Organization Name:DR. ANTHONY J. SURRUSCO, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:SURRUSCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-455-0435
Mailing Address - Street 1:421 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CLARENDON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-2701
Mailing Address - Country:US
Mailing Address - Phone:630-455-0435
Mailing Address - Fax:630-455-0437
Practice Address - Street 1:421 PARK AVE
Practice Address - Street 2:
Practice Address - City:CLARENDON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60514-2701
Practice Address - Country:US
Practice Address - Phone:630-455-0435
Practice Address - Fax:630-455-0437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006816111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02205510OtherBCBS
IL02205510OtherBCBS