Healthcare Provider Details

I. General information

NPI: 1902903610
Provider Name (Legal Business Name): PEDIATRIX MEDICAL GROUP OF ILLINOIS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 02/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E STATE ST
ROCKFORD IL
61104-2315
US

IV. Provider business mailing address

1500 CONCORD TER
SUNRISE FL
33323-2815
US

V. Phone/Fax

Practice location:
  • Phone: 815-489-4177
  • Fax: 815-490-5906
Mailing address:
  • Phone: 800-243-3839
  • Fax: 844-686-2961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ARNOLD M POOLE
Title or Position: SIGNING AUTHORITY
Credential:
Phone: 954-384-0175