Healthcare Provider Details

I. General information

NPI: 1487751335
Provider Name (Legal Business Name): ROCKFORD DERMATOLOGY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4338 MORSAY DR
ROCKFORD IL
61107-4877
US

IV. Provider business mailing address

4338 MORSAY DR
ROCKFORD IL
61107-4877
US

V. Phone/Fax

Practice location:
  • Phone: 815-399-6400
  • Fax: 815-399-4424
Mailing address:
  • Phone: 815-399-6400
  • Fax: 815-399-4424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number042617821
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number042617821
License Number StateIL

VIII. Authorized Official

Name: DR. LAKIMERLY MICHELLE COATES
Title or Position: PRESIDENT
Credential: MD
Phone: 815-399-6400