Provider Demographics
NPI:1104989409
Name:TRUSEWYCH, ZORIAN P (DO)
Entity type:Individual
Prefix:
First Name:ZORIAN
Middle Name:P
Last Name:TRUSEWYCH
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 1:1707 N 12TH ST
Mailing Address - Street 2:BLDG 29M
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301
Mailing Address - Country:US
Mailing Address - Phone:217-222-9487
Mailing Address - Fax:217-222-8578
Practice Address - Street 1:1707 N 12TH ST
Practice Address - Street 2:BLDG 29M
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301
Practice Address - Country:US
Practice Address - Phone:217-222-8641
Practice Address - Fax:217-222-8578
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077602207R00000X
IL036-077602207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00401311OtherRAIL ROAD MEDICARE
K18326Medicare ID - Type UnspecifiedBLESSING
D16720Medicare UPIN
ILK35683Medicare PIN