Basic Information
| Provider Information | |||||||||
| NPI: | 1811488109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAVON BEA HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ROCKFORD MEMORIAL HOSPITAL ILLINOIS CHILDREN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159715000 | ||||||||
| FaxNumber: | 8159680170 | ||||||||
| Practice Location | |||||||||
| Address1: | 8201 E RIVERSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611142300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159717000 | ||||||||
| FaxNumber: | 8159684795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2018 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 6087566000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HEALTH CORPORATION | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 0002048 | IL | Y | Hospitals | General Acute Care Hospital | Children |
No ID Information.