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General NPI Number Information
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NPI Number | 1154798916
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Entity Type | Organization
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Legal Business Name | THE BRIDGE CLINIC OF ROCKOFRD
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Dates
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Enumeration Date | 08/27/2015
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Last Update Date | 08/27/2015
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Provider Practice Location Address
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Address Line | 318 N CHURCH ST
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City | ROCKFORD
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State | IL
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Zip | 61101-1006
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Country | US
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Telephone | 815-494-1594
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 16024
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City | LOVES PARK
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State | IL
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Zip | 61132-6024
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Country | US
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Telephone | 815-494-1594
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Fax | 866-506-0931
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. ANNETTE OLIN
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Credential | M.D.
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Telephone | 815-494-1594
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number |
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License Number State |
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