Provider Demographics
NPI:1396728978
Name:BRUKASZ, PETER (MD)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:BRUKASZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PIOTR
Other - Middle Name:
Other - Last Name:BRUKASZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10510 S ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1934
Mailing Address - Country:US
Mailing Address - Phone:630-401-7102
Mailing Address - Fax:630-566-6879
Practice Address - Street 1:10510 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1934
Practice Address - Country:US
Practice Address - Phone:630-401-7102
Practice Address - Fax:630-566-6879
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111722202K00000X
IL36111722202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621679OtherBCBS OF IL
IL01621679OtherBCBS OF IL
ILI 37598Medicare UPIN
ILK 19826Medicare ID - Type UnspecifiedGROUP 950150
IL036111722 /01Medicaid