Basic Information
| Provider Information | |||||||||
| NPI: | 1700033628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KWAK | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2400 N ROCKTON AVE | ||||||||
| Address2: | ROCKFORD HEALTH PHYSICIANS | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159715000 | ||||||||
| FaxNumber: | 8159687830 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 N ROCKTON AVE | ||||||||
| Address2: | ROCKFORD HEALTH PHYSICIANS | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159715000 | ||||||||
| FaxNumber: | 8159687830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2008 | ||||||||
| LastUpdateDate: | 08/27/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036.120211 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 036120211 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.