Provider Demographics
NPI:1134273238
Name:SWEDISHAMERICAN HOSPTIAL
Entity type:Organization
Organization Name:SWEDISHAMERICAN HOSPTIAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-966-2084
Mailing Address - Street 1:PO BOX 1567
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-0067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3906 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1679
Practice Address - Country:US
Practice Address - Phone:815-282-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========006OtherTRICARE
IL0428510012Medicare NSC
IL=========006OtherTRICARE