Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RN0300X | Nephrologist | 036072316 | IL |
NPI | 1063414944 |
---|---|
Provider Name | Charles Sweeney |
First Address | Rockford, IL 61107-5089 |
Second Address | Rockford, IL 61107-5089 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2005 |
Last Update Date | 22/04/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036072316 | (05) | IL |
1616108 | BCBS (01) | IL |
31763600 | (05) | WI |
C45084 | (02) | |
P00605022 | RAILROAD MEDICARE (01) | IL |