| Crusader Clinic Broadway | |
|
1100 Broadway Rockford IL 61104-1429 | |
| (815) 490-1601 | |
| (815) 490-1625 |
| Full Name | Crusader Clinic Broadway |
|---|---|
| Speciality | Clinic/Center |
| Location | 1100 Broadway, Rockford, Illinois |
| Authorized Official Name and Position | Samuel Miller (PRESIDENT & CEO) |
| Authorized Official Contact | 8154901737 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Crusader Clinic Broadway 1100 Broadway Rockford IL 61104-1429 Ph: (815) 490-1600 | Crusader Clinic Broadway 1100 Broadway Rockford IL 61104-1429 Ph: (815) 490-1601 |
| NPI Number | 1265601488 |
|---|---|
| Provider Enumeration Date | 02/21/2008 |
| Last Update Date | 08/24/2022 |
| Medicare PECOS PAC ID | 5799682993 |
|---|---|
| Medicare Enrollment ID | O20081006000063 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1265601488 | NPI | - | NPPES |
| 103436 | Other | DORAL | |
| 027548 | Other | CHAMPUS | |
| 1011514778 | Other | BLUE CROSS BLUE SHIELD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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