Healthcare Provider Details

I. General information

NPI: 1356451546
Provider Name (Legal Business Name): BASSAM SOUFAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N PERRYVILLE RD
ROCKFORD IL
61114-8011
US

IV. Provider business mailing address

29624 NETWORK PL
CHICAGO IL
60673-1296
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax:
Mailing address:
  • Phone: 608-756-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number036077791
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036077791
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: