Basic Information
| Provider Information | |||||||||
| NPI: | 1003499278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENRICO | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1911 RIDGELAND RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611086321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157138107 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5666 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611082425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152262000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2021 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041442697 | IL | N | Nursing Service Providers | Registered Nurse | 367500000X | 209023436 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.