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Organization
NORTHERN ILLINOIS RETINA LTD
Active
Organization
NORTHERN ILLINOIS RETINA LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SUSAN M FOWELL M.D. (PRESIDENT)
(815) 226-4990
Entity
Organization
Contact information
Practice address
1235 N MULFORD RD, SUITE 100, ROCKFORD, IL 61107-3879
(815) 226-4990
(815) 226-9472
Mailing address
1235 N MULFORD RD, SUITE 100, ROCKFORD, IL 61107-3879
(815) 226-4990
(815) 226-9472
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
042006794
IL
207WX0107X
Retina Specialist (Ophthalmology) Physician
Primary
036073359
IL
Other
Enumeration date
12/17/2007
Last updated
07/06/2017
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