Provider Demographics
NPI:1639531759
Name:PETRUSEK, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:PETRUSEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27790 W HIGHWAY 22 STE 27
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-2396
Mailing Address - Country:US
Mailing Address - Phone:847-649-6000
Mailing Address - Fax:
Practice Address - Street 1:27790 W HIGHWAY 22 STE 27
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2396
Practice Address - Country:US
Practice Address - Phone:847-649-6000
Practice Address - Fax:847-649-6060
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.155766207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology