Provider Demographics
NPI:1558642843
Name:ROSECRANCE
Entity Type:Organization
Organization Name:ROSECRANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / PRESDIENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-391-1000
Mailing Address - Street 1:1021 N MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3877
Mailing Address - Country:US
Mailing Address - Phone:815-391-1000
Mailing Address - Fax:815-316-4726
Practice Address - Street 1:2406 AUBURN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-4495
Practice Address - Country:US
Practice Address - Phone:815-391-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04081261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04081Medicaid