Healthcare Provider Details

I. General information

NPI: 1548242712
Provider Name (Legal Business Name): MICHAEL SOO ROH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 MCFARLAND RD SUITE 300
ROCKFORD IL
61107-6801
US

IV. Provider business mailing address

PO BOX 735263 SUITE 300
CHICAGO IL
60673-5263
US

V. Phone/Fax

Practice location:
  • Phone: 815-316-2100
  • Fax: 815-316-2099
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number036105970
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036105970
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: