Provider Demographics
NPI:1912010273
Name:KULLBERG, FREDRIC C (MD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:C
Last Name:KULLBERG
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 1:535 ROXBURY RD
Mailing Address - Street 2:SUITE B600
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5076
Mailing Address - Country:US
Mailing Address - Phone:815-397-7212
Mailing Address - Fax:815-397-2539
Practice Address - Street 1:535 ROXBURY RD
Practice Address - Street 2:SUITE B600
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5076
Practice Address - Country:US
Practice Address - Phone:815-397-7212
Practice Address - Fax:815-397-2539
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 062004207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101 00574OtherBLUE CROSS BLUE SHIELD
IL036 062004Medicaid
IL290000247OtherRAILROAD MEDICARE
IL666470Medicare ID - Type Unspecified
IL036 062004Medicaid
IL290000247OtherRAILROAD MEDICARE