Provider Demographics
NPI:1245239284
Name:RIFKIN, GARY D (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:RIFKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 PHELPS AVE
Mailing Address - Street 2:SUITE 508
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2453
Mailing Address - Country:US
Mailing Address - Phone:815-229-2300
Mailing Address - Fax:815-229-3909
Practice Address - Street 1:129 PHELPS AVE
Practice Address - Street 2:SUITE 508
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2453
Practice Address - Country:US
Practice Address - Phone:815-229-2300
Practice Address - Fax:815-229-3909
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP05704Medicare ID - Type Unspecified
ILC41463Medicare UPIN
IL674520Medicare PIN