Provider Demographics
NPI:1649279225
Name:GELLER, STEPHEN CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CHARLES
Last Name:GELLER
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 1:4810 SPRING BROOK RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6358
Mailing Address - Country:US
Mailing Address - Phone:815-877-9730
Mailing Address - Fax:
Practice Address - Street 1:712 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4153
Practice Address - Country:US
Practice Address - Phone:815-654-7500
Practice Address - Fax:815-654-7440
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-050049207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD14351Medicare UPIN