Healthcare Provider Details

I. General information

NPI: 1740840404
Provider Name (Legal Business Name): MIDWEST INTEGRATED SURGEONS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2019
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 E RIVERSIDE BLVD
ROCKFORD IL
61114-4937
US

IV. Provider business mailing address

5875 E RIVERSIDE BLVD
ROCKFORD IL
61114-4937
US

V. Phone/Fax

Practice location:
  • Phone: 815-381-7431
  • Fax:
Mailing address:
  • Phone: 815-381-7431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LESLIE ELMER
Title or Position: MANAGER, CREDENTIALING AND RISK MAN
Credential:
Phone: 815-381-7431