Provider Demographics
NPI:1548227341
Name:ROCKFORD REHABILITATION MEDICINE, SC
Entity Type:Organization
Organization Name:ROCKFORD REHABILITATION MEDICINE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-965-9712
Mailing Address - Street 1:2825 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-3542
Mailing Address - Country:US
Mailing Address - Phone:815-965-9712
Mailing Address - Fax:
Practice Address - Street 1:2825 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-3542
Practice Address - Country:US
Practice Address - Phone:815-965-9712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
636320Medicare ID - Type Unspecified