Provider Demographics
NPI:1073679411
Name:ROCKFORD SURGICAL SERVICE, S.C.
Entity type:Organization
Organization Name:ROCKFORD SURGICAL SERVICE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:EDGCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-397-7900
Mailing Address - Street 1:5668 E STATE ST
Mailing Address - Street 2:SUITE1000
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2490
Mailing Address - Country:US
Mailing Address - Phone:815-397-7900
Mailing Address - Fax:815-397-7919
Practice Address - Street 1:5668 E STATE ST
Practice Address - Street 2:SUITE1000
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2490
Practice Address - Country:US
Practice Address - Phone:815-397-7900
Practice Address - Fax:815-397-7919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042000602086S0102X
IL208600000X, 2086S0129X, 208C00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Multi-Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Not Answered208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Not Answered208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10115298OtherBLUE SHIELD
IL96719OtherRAIL ROAD MEDICARE
IL=========Medicaid
IL=========Medicaid