Basic Information
| Provider Information | |||||||||
| NPI: | 1003029224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHWARTZ | ||||||||
| FirstName: | ELLISSA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICIAN ASSISTANT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | METTE | ||||||||
| OtherFirstName: | ELLISSA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHYSICIAN ASSISTANT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6830 VILLAGREEN VIEW | ||||||||
| Address2: | OSF MEDICAL GROUP-SPRINGCREEK | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611075639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152821339 | ||||||||
| FaxNumber: | 8152821298 | ||||||||
| Practice Location | |||||||||
| Address1: | 6830 VILLAGREEN VW | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611075639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152821339 | ||||||||
| FaxNumber: | 8152821298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 11/24/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085-002771 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA #052890 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2370-023 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 553180 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 834340 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 846930 | 01 | IL | MEDICARE GROUP PTAN | OTHER |