Provider Demographics
NPI:1982761144
Name:RUSKUSKY FOOT AND ANKLE CLINIC, LTD.
Entity Type:Organization
Organization Name:RUSKUSKY FOOT AND ANKLE CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUSKUSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-347-3886
Mailing Address - Street 1:3305 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6237
Mailing Address - Country:US
Mailing Address - Phone:309-347-3886
Mailing Address - Fax:309-347-4002
Practice Address - Street 1:3305 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6237
Practice Address - Country:US
Practice Address - Phone:309-347-3886
Practice Address - Fax:309-347-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060008112213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3960000001Medicare NSC