Healthcare Provider Details

I. General information

NPI: 1740491745
Provider Name (Legal Business Name): EAR NOSE & THROAT SPECIALISTS OF ROCKFORD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N MULFORD RD SUITE 10
ROCKFORD IL
61107-5189
US

IV. Provider business mailing address

435 N MULFORD RD SUITE 10
ROCKFORD IL
61107-5189
US

V. Phone/Fax

Practice location:
  • Phone: 815-399-5268
  • Fax: 815-399-3623
Mailing address:
  • Phone: 815-399-5268
  • Fax: 815-399-3623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number036067207
License Number StateIL

VIII. Authorized Official

Name: DR. JAMES MELVIN SEVERSON III
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 815-399-5268