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General NPI Number Information
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NPI Number | 1942483664
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Entity Type | Organization
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Legal Business Name | NORTHERN ILLINOIS RETINA LTD
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Dates
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Enumeration Date | 12/17/2007
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Last Update Date | 07/06/2017
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Provider Practice Location Address
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Address Line | 1235 N MULFORD RD SUITE 100
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City | ROCKFORD
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State | IL
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Zip | 61107-3879
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Country | US
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Telephone | 815-226-4990
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Fax | 815-226-9472
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Provider Business Mailing Address
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Address Line | 1235 N MULFORD RD SUITE 100
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City | ROCKFORD
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State | IL
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Zip | 61107-3879
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Country | US
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Telephone | 815-226-4990
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Fax | 815-226-9472
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Authorized Official
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Title or Position | PRESIDENT
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Name | SUSAN M FOWELL
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Credential | M.D.
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Telephone | 815-226-4990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 042006794
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207WX0107X
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Taxonomy Name | Retina Specialist (Ophthalmology) Physician
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License Number | 036073359
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License Number State | IL
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