Provider Demographics
NPI:1992297428
Name:INTEGRATIVE MEDICAL OF ROCKFORD
Entity type:Organization
Organization Name:INTEGRATIVE MEDICAL OF ROCKFORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:G
Authorized Official - Last Name:ERDMIER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:779-423-2044
Mailing Address - Street 1:863 S. PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:779-423-2044
Mailing Address - Fax:779-423-2045
Practice Address - Street 1:863 S PERRYVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4328
Practice Address - Country:US
Practice Address - Phone:779-423-2044
Practice Address - Fax:779-423-2045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty