Provider Demographics
NPI:1912216284
Name:IRENE BOSWELL MD PC
Entity Type:Organization
Organization Name:IRENE BOSWELL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:BOSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-332-1777
Mailing Address - Street 1:7445 NEWBURG RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4443
Mailing Address - Country:US
Mailing Address - Phone:815-332-1777
Mailing Address - Fax:815-332-1655
Practice Address - Street 1:7445 NEWBURG RD
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4443
Practice Address - Country:US
Practice Address - Phone:815-332-1777
Practice Address - Fax:815-332-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091532207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G18176Medicare UPIN
204899Medicare PIN