Basic Information
| Provider Information | |||||||||
| NPI: | 1003973827 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY SPECIALISTS OF LAKE COUNTY, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 S GREENLEAF ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475991111 | ||||||||
| FaxNumber: | 8475991148 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 S GREENLEAF ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475991111 | ||||||||
| FaxNumber: | 8475991148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | RAZA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8475991111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.