Basic Information
| Provider Information | |||||||||
| NPI: | 1346475159 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STERLING ROCK FALLS CLINIC, LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORAL & MAXILLOFACIAL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E MILLER RD | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610811252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156254790 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610813503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156325300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2009 | ||||||||
| LastUpdateDate: | 05/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | LEMAY | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRES.-BOARD OF DIRECTORS | ||||||||
| AuthorizedOfficialTelephone: | 8156254790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9815737 | 01 | IL | BLUE CROSS/ BLUE SHIELD | OTHER |