=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568025872
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOPKINS FAMILY MED & URGENT CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2019
-----------------------------------------------------
Last Update Date | 06/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4857 MANHATTAN DR
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61108-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-708-0116
-----------------------------------------------------
Fax | 815-708-0174
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4857 MANHATTAN DR
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61108-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-708-0116
-----------------------------------------------------
Fax | 815-708-0174
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/MANAGER
-----------------------------------------------------
Name | FIKISHA LATOYA WARDEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 815-708-0116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------