=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881879088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCKFORD PEDIATRIC PULMONOLOGY, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2008
-----------------------------------------------------
Last Update Date | 01/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7144 KLECKNER RD
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-6821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-636-7111
-----------------------------------------------------
Fax | 815-639-3526
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7144 KLECKNER RD
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-6821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-636-7111
-----------------------------------------------------
Fax | 815-639-3526
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. DAVID S. SHOBERG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 815-636-7111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0214X
-----------------------------------------------------
Taxonomy Name | Pediatric Pulmonology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------