Basic Information
| Provider Information | |||||||||
| NPI: | 1881679090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2780 MCFARLAND RD | ||||||||
| Address2: | PEDIATRICS | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611076807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159713070 | ||||||||
| FaxNumber: | 8156370040 | ||||||||
| Practice Location | |||||||||
| Address1: | 2780 MCFARLAND RD | ||||||||
| Address2: | PEDIATRICS | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611076807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159713070 | ||||||||
| FaxNumber: | 8156370040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 06/19/2015 | ||||||||
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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 | 208000000X | 036068700 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036068700 | 05 | IL | MEDICAID | 036068700 | 01 | IL | STATE LICENSE | OTHER |