Healthcare Provider Details

I. General information

NPI: 1508836107
Provider Name (Legal Business Name): ELIZABETH A PICKVANCE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N ROCKTON AVE
ROCKFORD IL
61103-3600
US

IV. Provider business mailing address

2400 N ROCKTON AVE
ROCKFORD IL
61103-3655
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-7400
  • Fax:
Mailing address:
  • Phone: 815-971-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number14838R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number24215
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD.14838R
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number036141771
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: