Basic Information
Provider Information | |||||||||
NPI: | 1144286840 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STILWELL | ||||||||
FirstName: | SUZANNE | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, CGC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STILWELL | ||||||||
OtherFirstName: | SUZIE | ||||||||
OtherMiddleName: | H | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS, CGC | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 6083 BUTTERCUP LN | ||||||||
Address2: |   | ||||||||
City: | ROCKFORD | ||||||||
State: | IL | ||||||||
PostalCode: | 611088111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8152279363 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2400 N ROCKTON AVE | ||||||||
Address2: | DEPT OF MEDICAL GENETICS, ROCKFORD MEMORIAL HOSPITAL | ||||||||
City: | ROCKFORD | ||||||||
State: | IL | ||||||||
PostalCode: | 611033655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8159715069 | ||||||||
FaxNumber: | 8159687830 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | 96235 |   | Y |   | Other Service Providers | Genetic Counselor, MS |   |
No ID Information.