Basic Information
| Provider Information | |||||||||
| NPI: | 1164174140 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROSECRANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 N MULFORD RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611073874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153871000 | ||||||||
| FaxNumber: | 8153164726 | ||||||||
| Practice Location | |||||||||
| Address1: | 2704 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159689300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2022 | ||||||||
| LastUpdateDate: | 01/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SCHUSTER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | FRANCIS | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8153875642 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.