=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891042552
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AZHAR KOTHAWALA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2012
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1235 N MULFORD RD STE 222
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-3879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-397-8400
-----------------------------------------------------
Fax | 815-229-0050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2202 HARLEM ROAD SUITE 200
-----------------------------------------------------
City | LOVES PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61111-2754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-877-4848
-----------------------------------------------------
Fax | 815-636-6125
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 036.140452
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 036.140452
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------