MEDICARE: SWEDISHAMERICAN HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner
2	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14D2010270	OTHER	IL	CLIA

General Provider Information

NPI Number	:	1205154440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SWEDISHAMERICAN HOSPITAL

Provider Business Mailing Address
First Line	:	PO BOX 1567
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61110-0067
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 E PRAIRIE ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-3107
Country	:	US
Telephone Number	:	779-696-9553
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	DON DANIELS
Credential	:
Telephone Number	:	815-966-2084

Provider Enumeration Date	:	05/12/2010
Last Update Date	:	06/30/2015

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Directions to “SWEDISHAMERICAN HOSPITAL ” Practice Location

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