Susan Provow, M.D.
Individual provider Active NPI Family Medicine Physician · Rock Falls, IL
NPI 1861580128 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1861580128
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Practice address
- 100 W 1St St
Rock Falls, IL 61071-1269 - Phone
- (815) 625-4790
- NPI assigned
- Oct 11, 2006
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20101019000956 | IL | Practitioner - Family Practice | 5890803928 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036077142 | IL | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| CGH Medical Center | Current | Accepting new patients | |
| Sterling Rock Falls Clinic | Past | Accepting new patients | |
| Sterling Rock Falls Clinic, LTD | Past | Accepting new patients |
Locations
711 S Division Ave
Polo, IL 61064
Phone (815) 946-3661
100 W 1st St
Rock Falls, IL 61071
Phone (815) 632-5366
101 E Miller Rd
Sterling, IL 61081
Phone (815) 632-5285
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | IL | Yes |
Addresses
Primary practice location
100 W 1St St
Rock Falls, IL 61071-1269
Mailing address
101 E Miller Rd
Sterling, IL 61081-1252
Phone (815) 625-4790
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 9815737 | Other | IL | BLUE CROSS BLUE SHIELD |
| 011542 | Other | IL | HEALTH ALLIANCE MEDICAL |
Other providers in Rock Falls, IL
- Oncall Imaging LLC
- Peak Professional Health Services
- Petersen Health & Wellness, LLC
- Long P Pham
- Breanna Preston
- Donald Lee Rastede
- Donna J Ripley
- Riverdale Elem SCH Dist 14
- Rock Falls Elem School Dist 13
- Lisa Ann Rodriguez
All providers in Rock Falls, IL · Family Medicine Physician in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.