Provider Demographics
NPI:1659073971
Name:KERRUISH, ROBERT DEAN III (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DEAN
Last Name:KERRUISH
Suffix:III
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 1:336 LATHROP AVE APT 603
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1450
Mailing Address - Country:US
Mailing Address - Phone:425-737-7794
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:888-584-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.082178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program