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General NPI Number Information
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NPI Number | 1902903610
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Entity Type | Organization
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Legal Business Name | PEDIATRIX MEDICAL GROUP OF ILLINOIS PC
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Dates
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Enumeration Date | 09/17/2006
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Last Update Date | 02/01/2018
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Provider Practice Location Address
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Address Line | 1401 E STATE ST
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City | ROCKFORD
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State | IL
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Zip | 61104-2315
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Country | US
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Telephone | 815-489-4177
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Fax | 815-490-5906
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Provider Business Mailing Address
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Address Line | 1500 CONCORD TER
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City | SUNRISE
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State | FL
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Zip | 33323-2815
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Country | US
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Telephone | 800-243-3839
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Fax | 844-686-2961
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Authorized Official
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Title or Position | SIGNING AUTHORITY
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Name | ARNOLD M POOLE
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Credential |
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Telephone | 954-384-0175
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2080P0203X
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Taxonomy Name | Pediatric Critical Care Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2080N0001X
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Taxonomy Name | Neonatal-Perinatal Medicine Physician
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License Number |
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License Number State |
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