Provider Demographics
NPI:1447207741
Name:ROCKFORD GASTROENTEROLOGY ASSOCIATES LTD
Entity Type:Organization
Organization Name:ROCKFORD GASTROENTEROLOGY ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-397-7340
Mailing Address - Street 1:401 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5075
Mailing Address - Country:US
Mailing Address - Phone:815-397-7340
Mailing Address - Fax:815-397-7388
Practice Address - Street 1:401 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5075
Practice Address - Country:US
Practice Address - Phone:815-397-7340
Practice Address - Fax:815-397-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042004145174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL692090Medicare PIN