Provider Demographics
NPI:1194786558
Name:ROCKFORD UROLOGICAL ASSOCIATES, LTD.
Entity type:Organization
Organization Name:ROCKFORD UROLOGICAL ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:PICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-398-4057
Mailing Address - Street 1:351 EXECUTIVE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5339
Mailing Address - Country:US
Mailing Address - Phone:815-398-4057
Mailing Address - Fax:815-398-0220
Practice Address - Street 1:351 EXECUTIVE PKWY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5339
Practice Address - Country:US
Practice Address - Phone:815-398-4057
Practice Address - Fax:815-398-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058803Medicaid
IL036099544Medicaid
IL036066868Medicaid
IL036080935Medicaid
IL036067790Medicaid
IL036051080Medicaid
IL036054674Medicaid
IL036054674Medicaid