Basic Information
| Provider Information | |||||||||
| NPI: | 1417912411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGUSTSSON MATHERS | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUDSON | ||||||||
| OtherFirstName: | ANN | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1601 PARKVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153955870 | ||||||||
| FaxNumber: | 8153955750 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 PARKVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153955870 | ||||||||
| FaxNumber: | 8153955750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036039266 | IL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 336008741 | 01 | IL | ILLINOIS DEA | OTHER | 036039266 | 01 | IL | STATE MEDICAL LICENSE | OTHER |