Healthcare Provider Details

I. General information

NPI: 1619368834
Provider Name (Legal Business Name): PORTABLE MEDICAL RESOURCES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 PHELPS AVE SUITE 406
ROCKFORD IL
61108-2453
US

IV. Provider business mailing address

129 PHELPS AVE SUITE 406
ROCKFORD IL
61108-2453
US

V. Phone/Fax

Practice location:
  • Phone: 815-397-5554
  • Fax: 815-550-0061
Mailing address:
  • Phone: 815-397-5554
  • Fax: 815-550-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MARTIN URBAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 815-397-5554