Individual provider Active NPI

Kirstin Fudge

  • Physician Assistant
  • Rockford, IL
National Provider Identifier
1689567133
Registry record updated Jun 2, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
Practice address
1401 E State St
Rockford, IL 61104-2315
Phone
(779) 696-4410
NPI assigned
Jun 2, 2025
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 2, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Surgical Physician Assistant 363AS0400X
Medical Physician Assistant 363AM0700X
Physician Assistant 363A00000X Primary

Addresses

Primary practice location

1401 E State St
Rockford, IL 61104-2315

Mailing address

1401 E State St
Rockford, IL 61104-2315
Phone (779) 696-4410

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services: Yes
  • Medical equipment: Yes
  • Home health: Yes
  • Power mobility devices: Yes
  • Hospice: No
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20250920000771 IL Practitioner - Physician Assistant 9931603016 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2025
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Swedishamerican HospitalGroup PAC ID 5799698346, 386 clinicians

Practice addresses (Care Compare)

1401 E State St
Rockford, IL 61104-2315
Phone (815) 489-4400

6824 Newburg Rd
Sa Valley
Rockford, IL 61108-4330
Phone (779) 696-7610

Hospital & facility affiliations

  • Uw Health Hospital, Rockford, IL, CCN 140228

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

Practice roles

OrganizationSpecialtyStatusNew patients
Swedishamerican Hospital CurrentSince Sep 8, 2025 Accepting new patients
Swedishamerican Hospital CurrentSince Sep 8, 2025 Accepting new patients

Locations

1401 E State St
Rockford, IL 61104
Phone (815) 489-4267

6824 Newburg Rd
Rockford, IL 61108
Phone (779) 696-7610

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 1

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1748822400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1748822400000",
    "number": "1689567133",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1401 E STATE ST",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611042315",
            "telephone_number": "779-696-4410"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1401 E STATE ST",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611042315",
            "telephone_number": "779-696-4410"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FUDGE",
        "first_name": "KIRSTIN",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2025-06-02",
        "last_updated": "2025-06-02",
        "certification_date": "2025-06-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Rockford, IL

Sources for this page

Verify at the official NPI Registry.