Basic Information
Provider Information | |||||||||
NPI: | 1114431418 | ||||||||
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: | 8153875600 | ||||||||
FaxNumber: | 8153164726 | ||||||||
Practice Location | |||||||||
Address1: | 923 N VERMILION ST | ||||||||
Address2: |   | ||||||||
City: | DANVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 618323047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8153911000 | ||||||||
FaxNumber: | 8153915040 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2017 | ||||||||
LastUpdateDate: | 04/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHUSTER | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | FRANCIS | ||||||||
AuthorizedOfficialTitleorPosition: | SVP AND CFO | ||||||||
AuthorizedOfficialTelephone: | 8153875642 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/19/2022 |
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) |
No ID Information.