Basic Information
| Provider Information | |||||||||
| NPI: | 1871570978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSANWO | ||||||||
| FirstName: | MATILDA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 STATION DR | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600147978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8154558044 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 STATION DR | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8154558044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036104686 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036104686 | 01 | IL | STATE LICENSE | OTHER | P00424928 | 01 | IL | RR MEDICARE | OTHER | 0361046863 | 05 | IL | MEDICAID |