MEDICARE: ROSECRANCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1063891646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSECRANCE

Provider Business Mailing Address
First Line	:	1021 N MULFORD RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-3877
Country	:	US
Telephone Number	:	815-391-1000
Fax Number	:	815-316-4726

Provider Business Practice Location Address
First Line	:	3701 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3601
Country	:	US
Telephone Number	:	815-391-1000
Fax Number	:	815-316-4726

Authorized Official
Title or Position	:	CEO / PRESIDENT
Name	:	PHILIP EATON
Credential	:
Telephone Number	:	815-391-1000

Provider Enumeration Date	:	05/28/2015
Last Update Date	:	08/11/2022

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