Provider Demographics
NPI:1376698332
Name:ROCHELLE FAMILY HEALTH CARE
Entity Type:Organization
Organization Name:ROCHELLE FAMILY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PITAMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-562-3784
Mailing Address - Street 1:PO BOX 4474
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-0974
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:822 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1766
Practice Address - Country:US
Practice Address - Phone:815-562-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0007132022OtherBLUE SHIELD
IL0007132022OtherBLUE SHIELD
IL212832Medicare ID - Type UnspecifiedGROUP