Provider Demographics
NPI:1750485355
Name:OTTAWA MEDICAL CENTER, P.C.
Entity Type:Organization
Organization Name:OTTAWA MEDICAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-433-1010
Mailing Address - Street 1:1614 E NORRIS DR
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-3681
Mailing Address - Country:US
Mailing Address - Phone:815-433-1010
Mailing Address - Fax:815-431-3259
Practice Address - Street 1:1614 E NORRIS DR
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-3681
Practice Address - Country:US
Practice Address - Phone:815-433-1010
Practice Address - Fax:815-431-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0762970001Medicare NSC