Provider Demographics
NPI:1174636658
Name:ROCKFORD ASSOCIATED PATHOLOGISTS LTD
Entity Type:Organization
Organization Name:ROCKFORD ASSOCIATED PATHOLOGISTS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-489-4267
Mailing Address - Street 1:1401 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2315
Mailing Address - Country:US
Mailing Address - Phone:815-489-4267
Mailing Address - Fax:815-395-3967
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:815-489-4267
Practice Address - Fax:815-395-3967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36063669207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205367Medicare PIN