# DOUGLAS A KRUSE MD LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1518049204
- **Authorized official:** MR. DOUGLAS A KRUSE MD (OWNER)
- **Authorized official phone:** (618) 526-2222

## Contact information

- **Practice address:** 9495 HOLY CROSS LN, SUITE 103, BREESE, IL 62230-3510
- **Practice address phone:** (618) 526-2222
- **Practice address fax:** (618) 526-7680
- **Mailing address:** 9495 HOLY CROSS LN, SUITE 103, BREESE, IL 62230-3510
- **Mailing address phone:** (618) 526-2222
- **Mailing address fax:** (618) 526-7680

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 036098255 | IL | Yes |

## Other

- **Enumeration date:** 10/20/2006
- **Last updated:** 06/13/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 036098255 | — | IL |
| 01 | — | IL BLUESHIELD | 01427671 | IL |