Provider Demographics
NPI:1619900040
Name:HOUSECALL PHYSICIANS GROUP OF ROCKFORD S C
Entity Type:Organization
Organization Name:HOUSECALL PHYSICIANS GROUP OF ROCKFORD S C
Other - Org Name:HOUSE CALLS OF GREATER CHICAGO, S.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEHAAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-312-5810
Mailing Address - Street 1:124 N WATER ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3960
Mailing Address - Country:US
Mailing Address - Phone:815-312-5810
Mailing Address - Fax:815-312-5811
Practice Address - Street 1:124 N WATER ST
Practice Address - Street 2:SUITE 208
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3960
Practice Address - Country:US
Practice Address - Phone:815-312-5810
Practice Address - Fax:815-312-5811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL411750Medicare UPIN