Basic Information
| Provider Information | |||||||||
| NPI: | 1922037308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROCHE | ||||||||
| FirstName: | FLORENCE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 326 HOME AVE | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603023404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735902562 | ||||||||
| FaxNumber: | 7087630245 | ||||||||
| Practice Location | |||||||||
| Address1: | RESURRECTION IMMEDIATE CARE CENTER | ||||||||
| Address2: | 7230 W. NORTH AVE, STE 106 B | ||||||||
| City: | ELMWOOD PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607074262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084533000 | ||||||||
| FaxNumber: | 7084534660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
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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 | 036108887 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036108887 | 05 | IL | MEDICAID | 1619414 | 01 | IL | BCBS GROUP | OTHER | 3633309286030501 | 05 | IL | MEDICAID |