Provider Demographics
NPI:1740491745
Name:EAR NOSE & THROAT SPECIALISTS OF ROCKFORD SC
Entity type:Organization
Organization Name:EAR NOSE & THROAT SPECIALISTS OF ROCKFORD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:SEVERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:815-399-5268
Mailing Address - Street 1:435 N MULFORD RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5189
Mailing Address - Country:US
Mailing Address - Phone:815-399-5268
Mailing Address - Fax:815-399-3623
Practice Address - Street 1:435 N MULFORD RD
Practice Address - Street 2:SUITE 10
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5189
Practice Address - Country:US
Practice Address - Phone:815-399-5268
Practice Address - Fax:815-399-3623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067207305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067207Medicaid
IL364350Medicare ID - Type Unspecified
IL036067207Medicaid