Basic Information
Provider Information | |||||||||
NPI: | 1306504071 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKFORD ORTHOPEDIC ASSOCIATES, LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5875 E RIVERSIDE BLVD | ||||||||
Address2: |   | ||||||||
City: | ROCKFORD | ||||||||
State: | IL | ||||||||
PostalCode: | 611144937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8153817431 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 150 S EASTWOOD DR | ||||||||
Address2: |   | ||||||||
City: | WOODSTOCK | ||||||||
State: | IL | ||||||||
PostalCode: | 60098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8153817431 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2021 | ||||||||
LastUpdateDate: | 11/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ELMER | ||||||||
AuthorizedOfficialFirstName: | LESLIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING AND RISK MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8153817431 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.