Provider Demographics
NPI:1093716318
Name:MEDCHOICE MEDICAL CENTER LTD
Entity type:Organization
Organization Name:MEDCHOICE MEDICAL CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:R
Authorized Official - Last Name:BALUGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-397-4142
Mailing Address - Street 1:PO BOX 6107
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61125-1107
Mailing Address - Country:US
Mailing Address - Phone:815-397-4142
Mailing Address - Fax:815-307-4144
Practice Address - Street 1:6905 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2692
Practice Address - Country:US
Practice Address - Phone:815-397-4142
Practice Address - Fax:815-397-4144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-007683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146702OtherMEDICARE PART A
IL10120419OtherBLUE CROSS BLUE SHIELD
IL447370OtherMEDICARE PART B
IL5378720001Medicare NSC