Provider Demographics
NPI:1659325413
Name:AGRUSA, JEROME JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:JAMES
Last Name:AGRUSA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16651 21 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2603
Mailing Address - Country:US
Mailing Address - Phone:586-263-5611
Mailing Address - Fax:586-263-5130
Practice Address - Street 1:16651 21 MILE RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-2603
Practice Address - Country:US
Practice Address - Phone:586-263-5611
Practice Address - Fax:586-263-5130
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004758111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1771391Medicaid
MI950E01772OtherBLUE CROSS BLUE SHIELD
MIU16591Medicare UPIN
MI950E01772OtherBLUE CROSS BLUE SHIELD