Provider Demographics
NPI:1164845459
Name:INTEGRATIVE MEDICAL ASSOCIATES OF ROCKFORD, LLC
Entity Type:Organization
Organization Name:INTEGRATIVE MEDICAL ASSOCIATES OF ROCKFORD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:NITZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN
Authorized Official - Phone:815-289-4697
Mailing Address - Street 1:4007 CUSHMAN CLOSE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6106
Mailing Address - Country:US
Mailing Address - Phone:815-289-4697
Mailing Address - Fax:
Practice Address - Street 1:1639 N ALPINE RD
Practice Address - Street 2:SUITE 502
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1449
Practice Address - Country:US
Practice Address - Phone:815-289-4697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105695OtherPHYSICIAN LICENSE