Provider Demographics
NPI:1750344404
Name:COLLINS, JOHN C (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:COLLINS
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 1:535 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5076
Mailing Address - Country:US
Mailing Address - Phone:815-387-1717
Mailing Address - Fax:815-387-1718
Practice Address - Street 1:535 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5076
Practice Address - Country:US
Practice Address - Phone:815-387-1717
Practice Address - Fax:815-387-1718
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010849332084N0400X
IL036-0595632084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4678381Medicaid
MI1750344404Medicaid
MI1417961137OtherBCBSM - BRONSON
MI4733821Medicaid
MI4678381Medicaid
MI0P18850003Medicare ID - Type Unspecified
MI0C96003015Medicare ID - Type Unspecified
MI1750344404Medicaid