Provider Demographics
NPI:1518912765
Name:SEVERSON, JAMES MELVIN III (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MELVIN
Last Name:SEVERSON
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:435 N MULFORD RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5189
Mailing Address - Country:US
Mailing Address - Phone:815-399-5268
Mailing Address - Fax:815-399-3623
Practice Address - Street 1:435 N MULFORD RD
Practice Address - Street 2:SUITE 10
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5189
Practice Address - Country:US
Practice Address - Phone:815-399-5268
Practice Address - Fax:815-399-3623
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2007-09-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist