Organization
SWEDISHAMERICAN HOSPITAL
Active
Other names
SA State Street OB/Gyn
Organization subpart
No
Provider details
NPI number
Authorized official
DON DANIELS (VP)
(815) 966-2084
Entity
Organization
Contact information
Practice address
1415 E STATE ST, 8TH FLOOR, ROCKFORD, IL 61104
(779) 696-9120
Mailing address
PO BOX 78866, MILWAUKEE, WI 53278-8866
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
079
TRICARE SUFFIX #
IL
01
—
14D0941317
CLIA
IL
Enumeration date
04/19/2013
Last updated
07/12/2018
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