Basic Information
| Provider Information | |||||||||
| NPI: | 1750344404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 535 ROXBURY RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611075076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153871717 | ||||||||
| FaxNumber: | 8153871718 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 ROXBURY RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611075076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153871717 | ||||||||
| FaxNumber: | 8153871718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 01/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4301084933 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 036-059563 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 4678381 | 05 | MI | MEDICAID | 1750344404 | 05 | MI | MEDICAID | 1417961137 | 01 | MI | BCBSM - BRONSON | OTHER | 4733821 | 05 | MI | MEDICAID |