Provider Demographics
NPI:1417144577
Name:TAKATA ROSSI, JANICE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JANICE
Middle Name:L
Last Name:TAKATA ROSSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 E GREENWOOD
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550
Mailing Address - Country:US
Mailing Address - Phone:309-265-4110
Mailing Address - Fax:309-263-0156
Practice Address - Street 1:465 E. GREENWOOD
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550
Practice Address - Country:US
Practice Address - Phone:309-265-4110
Practice Address - Fax:309-263-0156
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065144Medicaid
ILK25537Medicare UPIN
IL036065144Medicaid