Basic Information
| Provider Information | |||||||||
| NPI: | 1306838255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARRY | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 PARKVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153955861 | ||||||||
| FaxNumber: | 8153955575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159721000 | ||||||||
| FaxNumber: | 8159721086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 52444 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 9701754 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 036151881 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80117751 | 01 | NC | RAILROAD MEDICARE | OTHER | 1093M | 01 | NC | BCBS NC | OTHER | 891093M | 05 | NC | MEDICAID |