MEDICARE: DR. STEPHEN T NITZ M.D.

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	207Q00000X	Family Medicine Physician	036105695	IL
2	207Q00000X	Family Medicine Physician	57636	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036105695	OTHER	IL	IL STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518958651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN T NITZ M.D.

Provider Business Mailing Address
First Line	:	7177 CRIMSON RIDGE DR
Second Line	:	STE 5
City	:	ROCKFORD
State	:	IL
Zip	:	61107-6235
Country	:	US
Telephone Number	:	815-395-5851
Fax Number	:	815-395-5644

Provider Business Practice Location Address
First Line	:	7177 CRIMSON RIDGE DR
Second Line	:	STE 5
City	:	ROCKFORD
State	:	IL
Zip	:	61107-6235
Country	:	US
Telephone Number	:	815-734-6061
Fax Number	:	815-734-9021

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	12/12/2019

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