Provider Demographics
NPI:1720078108
Name:HRUSKOVICH, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:HRUSKOVICH
Suffix:
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 1:211 N EDDY ST.
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3096
Mailing Address - Country:US
Mailing Address - Phone:574-246-8816
Mailing Address - Fax:574-204-6345
Practice Address - Street 1:211 N EDDY ST.
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3096
Practice Address - Country:US
Practice Address - Phone:574-246-8816
Practice Address - Fax:574-204-6345
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC52696207Q00000X
MI4301116232207Q00000X
DCMD046481207Q00000X
ND15405207Q00000X
TXR9778207Q00000X
IN01043972A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200152430Medicaid
IN146470DMedicare ID - Type Unspecified
IN200152430Medicaid