Provider Demographics
NPI:1881679090
Name:POTTS, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:POTTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 MCFARLAND RD
Mailing Address - Street 2:PEDIATRICS
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6807
Mailing Address - Country:US
Mailing Address - Phone:815-971-3070
Mailing Address - Fax:815-637-0040
Practice Address - Street 1:2780 MCFARLAND RD
Practice Address - Street 2:PEDIATRICS
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6807
Practice Address - Country:US
Practice Address - Phone:815-971-3070
Practice Address - Fax:815-637-0040
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068700Medicaid
IL036068700OtherSTATE LICENSE
IL036068700Medicaid
IL036068700OtherSTATE LICENSE