=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619900040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOUSECALL PHYSICIANS GROUP OF ROCKFORD S C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 04/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 N WATER ST SUITE 208
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-3960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-312-5810
-----------------------------------------------------
Fax | 815-312-5811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 N WATER ST SUITE 208
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-3960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-312-5810
-----------------------------------------------------
Fax | 815-312-5811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHARLES S. DEHAAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 815-312-5810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------