Provider Demographics
NPI:1740247535
Name:ROCKFORD RADIOLOGY ASSOC
Entity type:Organization
Organization Name:ROCKFORD RADIOLOGY ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:VITTORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-227-2468
Mailing Address - Street 1:PO BOX 1790
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53008-1790
Mailing Address - Country:US
Mailing Address - Phone:815-327-2468
Mailing Address - Fax:866-769-8052
Practice Address - Street 1:5666 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-327-2468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32681000Medicaid
IL=========Medicaid
WI32681000Medicaid