=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417134701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCKFORD REGIONAL SPECIALTY LAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2008
-----------------------------------------------------
Last Update Date | 01/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 973 FEATHERSTONE RD SUITE 101
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-5912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-986-3737
-----------------------------------------------------
Fax | 815-986-3748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 973 FEATHERSTONE RD SUITE 101
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-5912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-986-3737
-----------------------------------------------------
Fax | 815-986-3748
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. RICHARD J CRONIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-986-3757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------