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General NPI Number Information
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NPI Number | 1164845459
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE MEDICAL ASSOCIATES OF ROCKFORD, LLC
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Dates
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Enumeration Date | 01/23/2014
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Last Update Date | 01/23/2014
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Provider Practice Location Address
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Address Line | 1639 N ALPINE RD SUITE 502
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City | ROCKFORD
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State | IL
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Zip | 61107-1449
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Country | US
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Telephone | 815-289-4697
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Fax |
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Provider Business Mailing Address
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Address Line | 4007 CUSHMAN CLOSE
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City | ROCKFORD
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State | IL
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Zip | 61114-6106
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Country | US
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Telephone | 815-289-4697
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. STEPHEN T NITZ
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Credential | PHYSICIAN
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Telephone | 815-289-4697
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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