1588746101 NPI number — STERLING ROCK FALLS CLINIC

Table of content: (NPI 1588746101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588746101 NPI number — STERLING ROCK FALLS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STERLING ROCK FALLS CLINIC
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:
6
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:
1588746101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E MILLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61081-1252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-625-4790
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1321 N GALENA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DIXON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61021-1009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-284-1600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEMAY
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP-BOARD OF DIRECTORS
Authorized Official Telephone Number:
815-625-4790

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9815737 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0423280003 . This is a "DME" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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