Provider Demographics
NPI:1851394696
Name:AFFILIATED SURGEONS OF ROCKFORD LLC
Entity Type:Organization
Organization Name:AFFILIATED SURGEONS OF ROCKFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLAZURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-489-6034
Mailing Address - Street 1:PO BOX 15730
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61132-5730
Mailing Address - Country:US
Mailing Address - Phone:815-964-3333
Mailing Address - Fax:815-964-3134
Practice Address - Street 1:2300 N ROCKTON AVE
Practice Address - Street 2:STE 304
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3619
Practice Address - Country:US
Practice Address - Phone:815-964-3333
Practice Address - Fax:815-964-3134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361045332085R0204X
IL036062833208600000X
IL036048085208600000X
IL036064323208600000X
IL0360716662086S0122X
IL0360636472086S0129X
IL0361011792086S0129X
IL0360672682086S0129X
IL036064410208C00000X
IL085002211363AS0400X
IL209004303363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204575400OtherOWCP GROUP NUMBER
IL10132011OtherBCBS GROUP NUMBER
IL204575400OtherOWCP GROUP NUMBER
IL200457Medicare PIN