Provider Demographics
NPI:1497739569
Name:KRUSKOL, BRYAN M (DO)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:M
Last Name:KRUSKOL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 GATEWAY DR STE 201
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3192
Mailing Address - Country:US
Mailing Address - Phone:815-766-7021
Mailing Address - Fax:815-758-5690
Practice Address - Street 1:1850 GATEWAY DR STE 201
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:815-766-7021
Practice Address - Fax:815-758-5690
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102450207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102450Medicaid
IL01932073OtherBLUE CROSS BLUE SHIELD
IL212939Medicare PIN
IL212941Medicare PIN
IL01932073OtherBLUE CROSS BLUE SHIELD
ILH80636Medicare UPIN
ILK32512Medicare PIN