=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760259998
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST REPRODUCTIVE HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2023
-----------------------------------------------------
Last Update Date | 12/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4236 MARAY DR
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-4964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-216-5288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4236 MARAY DR
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-4964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. DOUG LAUBE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 608-216-5288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VC0300X
-----------------------------------------------------
Taxonomy Name | Complex Family Planning Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------