Provider Demographics
NPI:1033641394
Name:BRUSALIS, CHRISTOPHER MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:BRUSALIS
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:PO BOX 29234
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-9234
Mailing Address - Country:US
Mailing Address - Phone:516-743-3036
Mailing Address - Fax:516-743-3576
Practice Address - Street 1:333 EARLE OVINGTON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-3645
Practice Address - Country:US
Practice Address - Phone:516-743-3036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.159907207XX0005X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program