Healthcare Provider Details

I. General information

NPI: 1497736409
Provider Name (Legal Business Name): SURGICAL ASSOCIATES OF NORTHERN ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N ROCKTON AVE SUITE 510
ROCKFORD IL
61103-3600
US

IV. Provider business mailing address

2350 N ROCKTON AVE SUITE 510
ROCKFORD IL
61103-3600
US

V. Phone/Fax

Practice location:
  • Phone: 815-963-3426
  • Fax: 815-963-3428
Mailing address:
  • Phone: 815-963-3426
  • Fax: 815-963-3428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY ANN RAUTER
Title or Position: ASST OFFICE MANAGER
Credential:
Phone: 815-963-3426