Provider Demographics
NPI:1417067695
Name:BULLOCK, ERIC D (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:D
Last Name:BULLOCK
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 1:2400 N. ROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3655
Mailing Address - Country:US
Mailing Address - Phone:815-971-5000
Mailing Address - Fax:
Practice Address - Street 1:2400 N ROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3655
Practice Address - Country:US
Practice Address - Phone:815-971-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104034208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104034Medicaid
IL991600Medicare PIN
IL036104034Medicaid