Northern Illinois Retina LTD

Primary specialty

Retina Specialist (Ophthalmology) PhysicianTaxonomy code 207WX0107X

License

036073359 Issued in IL

Legal business name

NORTHERN ILLINOIS RETINA LTD

Practice address

1235 N Mulford Rd
Suite 100
Rockford, IL 61107-3879

Phone

(815) 226-4990

Fax

(815) 226-9472

NPI assigned

Dec 17, 2007

Last updated

Jul 6, 2017By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Susan M Fowell, M.D.NPI 1821091075

Title

President

Phone

(815) 226-4990

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Susan M Fowell, MD

  • Retina Specialist (Ophthalmology) Physician
  • Rockford, IL
  • NPI 1821091075

  Single Specialty

  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1197849600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1499299200000",
    "number": "1942483664",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1235 N MULFORD RD",
            "address_2": "SUITE 100",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611073879",
            "telephone_number": "815-226-4990",
            "fax_number": "815-226-9472"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1235 N MULFORD RD",
            "address_2": "SUITE 100",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611073879",
            "telephone_number": "815-226-4990",
            "fax_number": "815-226-9472"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHERN ILLINOIS RETINA LTD",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-17",
        "last_updated": "2017-07-06",
        "status": "A",
        "authorized_official_last_name": "FOWELL",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "815-226-4990",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "IL",
            "license": "042006794",
            "primary": false
        },
        {
            "code": "207WX0107X",
            "taxonomy_group": "",
            "desc": "Ophthalmology, Retina Specialist",
            "state": "IL",
            "license": "036073359",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1942483664",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Northern Illinois Imaging
• Northern Illinois Medical Group S. C.
• Northern Illinois Nephrology
• Northern Illinois Nephrology, S.C
• Northern Illinois Optical Co., Inc.
• Northern Illinois Scanning
• Northern Illinois Trauma Regional Orthopaedics, LLC
• Northern Illinois Vein Clinic, LLC
• Northern Illinois Women's Center
• Northern Prosthetics & Orthopedic Inc

• Retina Specialist (Ophthalmology) Physician in Rockford, IL
• Providers in Rockford, IL by specialty
• Retina Specialist (Ophthalmology) Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.