Basic Information
| Provider Information | |||||||||
| NPI: | 1326064296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JANICE TAKATA ROSSI MD SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 SO FOURTH | ||||||||
| Address2: | STE 140 | ||||||||
| City: | MORTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092636154 | ||||||||
| FaxNumber: | 3092636111 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SO FOURTH | ||||||||
| Address2: | STE 140 | ||||||||
| City: | MORTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092636154 | ||||||||
| FaxNumber: | 3092636111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 12/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | TAKATA ROSSI | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | LOURENE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3092636154 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-065144 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036065144 | 05 | IL | MEDICAID |