1558599803 NPI number — ROSECRANCE, INC.

Table of content: (NPI 1558599803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558599803 NPI number — ROSECRANCE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSECRANCE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558599803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 N UNIVERSITY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61107-5317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-391-1000
Provider Business Mailing Address Fax Number:
815-394-5041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 N. COURT STREET
Provider Second Line Business Practice Location Address:
METHODIST CHURCH
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61103-6802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-391-1000
Provider Business Practice Location Address Fax Number:
815-391-5040
Provider Enumeration Date:
06/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EATON
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
815-391-0100

Provider Taxonomy Codes

  • Taxonomy code: 3245S0500X , with the licence number:  A-0601-0026-A , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A-0601-0026-A , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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