Provider Demographics
NPI:1265462089
Name:STAVIG, ROLF R (MD)
Entity Type:Individual
Prefix:
First Name:ROLF
Middle Name:R
Last Name:STAVIG
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 1:820 S IL ROUTE 59
Mailing Address - Street 2:SUITE A
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-1694
Mailing Address - Country:US
Mailing Address - Phone:630-483-5930
Mailing Address - Fax:630-483-5939
Practice Address - Street 1:820 S IL ROUTE 59
Practice Address - Street 2:SUITE A
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-1694
Practice Address - Country:US
Practice Address - Phone:630-483-5930
Practice Address - Fax:630-483-5939
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3631498336019001OtherCDPG HFS PAYEE ID
IL0222075OtherBLUE CROSS GROUP NUMBER
IL36-3149833OtherTAX IDENTIFICATION NUMBER
IL036075767Medicaid
ILE19088Medicare UPIN
IL036075767Medicaid
IL0222075OtherBLUE CROSS GROUP NUMBER