Provider Demographics
NPI:1871536763
Name:ROCKFORD GASTROENTEROLOGY ASSOCIATES, LTD.
Entity type:Organization
Organization Name:ROCKFORD GASTROENTEROLOGY ASSOCIATES, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-397-7340
Mailing Address - Street 1:401 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5075
Mailing Address - Country:US
Mailing Address - Phone:815-397-7340
Mailing Address - Fax:815-397-7388
Practice Address - Street 1:401 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5075
Practice Address - Country:US
Practice Address - Phone:815-397-7340
Practice Address - Fax:815-397-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL141059Medicare PIN