Provider Demographics
NPI:1518958651
Name:NITZ, STEPHEN T (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:T
Last Name:NITZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7177 CRIMSON RIDGE DR
Mailing Address - Street 2:STE 5
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6235
Mailing Address - Country:US
Mailing Address - Phone:815-395-5851
Mailing Address - Fax:815-395-5644
Practice Address - Street 1:7177 CRIMSON RIDGE DR
Practice Address - Street 2:STE 5
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6235
Practice Address - Country:US
Practice Address - Phone:815-734-6061
Practice Address - Fax:815-734-9021
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2019-12-12
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Provider Licenses
StateLicense IDTaxonomies
IL036105695207Q00000X
WI57636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105695OtherIL STATE LICENSE
IL036105695Medicaid
IL202404Medicare PIN
IL036105695Medicaid