Healthcare Provider Details

I. General information

NPI: 1821026147
Provider Name (Legal Business Name): JOE O'SABEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 E RIVERSIDE BLVD SUITE 103
ROCKFORD IL
61114-4421
US

IV. Provider business mailing address

6451 E RIVERSIDE BLVD SUITE 103
ROCKFORD IL
61114-4421
US

V. Phone/Fax

Practice location:
  • Phone: 815-639-9900
  • Fax:
Mailing address:
  • Phone: 815-639-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.118972
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number036.118972
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036.118972
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: