Basic Information
Provider Information | |||||||||
NPI: | 1013364454 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROSECRANCE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1021 N MULFORD RD | ||||||||
Address2: |   | ||||||||
City: | ROCKFORD | ||||||||
State: | IL | ||||||||
PostalCode: | 611073877 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8153911000 | ||||||||
FaxNumber: | 8153164726 | ||||||||
Practice Location | |||||||||
Address1: | 1105 CARROLL AVE | ||||||||
Address2: |   | ||||||||
City: | URBANA | ||||||||
State: | IL | ||||||||
PostalCode: | 61802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8153911000 | ||||||||
FaxNumber: | 8153164726 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2016 | ||||||||
LastUpdateDate: | 09/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EATON | ||||||||
AuthorizedOfficialFirstName: | PHIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO / PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8153911000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 04081 | 05 | IL |   | MEDICAID |