Basic Information
| Provider Information | |||||||||
| NPI: | 1750357620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZIMMERMAN | ||||||||
| FirstName: | PHIL | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 PARKVIEW AVE | ||||||||
| Address2: | S200 | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153955851 | ||||||||
| FaxNumber: | 8153958644 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | MT MORRIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610541646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157346061 | ||||||||
| FaxNumber: | 8157349021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3360122024 | 01 | IL | CONTROLLED SUBSTANCE | OTHER |