Basic Information
| Provider Information | |||||||||
| NPI: | 1316334287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRIPP | ||||||||
| FirstName: | MARIAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8201 E RIVERSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611142300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159714066 | ||||||||
| FaxNumber: | 8159719299 | ||||||||
| Practice Location | |||||||||
| Address1: | 8201 E RIVERSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611142300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159714066 | ||||||||
| FaxNumber: | 8159719299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2015 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | 036147046 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 036147046 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 125067058 | 05 | IL | MEDICAID | 1316334287 | 05 | WI | MEDICAID |