Provider Demographics
NPI:1013077619
Name:PSYCHIATRIC ASSOCIATES OF ROCKFORD SC
Entity Type:Organization
Organization Name:PSYCHIATRIC ASSOCIATES OF ROCKFORD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-965-8505
Mailing Address - Street 1:6078 PALO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8117
Mailing Address - Country:US
Mailing Address - Phone:815-398-9360
Mailing Address - Fax:815-398-1028
Practice Address - Street 1:6078 PALO VERDE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8117
Practice Address - Country:US
Practice Address - Phone:815-398-9360
Practice Address - Fax:815-398-1028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL645540Medicare ID - Type Unspecified