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:
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 NEWLAND CT
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-1348
Mailing Address - Country:US
Mailing Address - Phone:586-216-0661
Mailing Address - Fax:
Practice Address - Street 1:3775 NEWLAND CT
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48316-1348
Practice Address - Country:US
Practice Address - Phone:586-216-0661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004758111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950E01772OtherBLUE CROSS BLUE SHIELD
MI1771391Medicaid
MIU16591Medicare UPIN
MI950E01772OtherBLUE CROSS BLUE SHIELD