Basic Information
Provider Information | |||||||||
NPI: | 1245761295 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKE COUNTY PRIMARY CARE S.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6037 | ||||||||
Address2: |   | ||||||||
City: | WAUCONDA | ||||||||
State: | IL | ||||||||
PostalCode: | 600846037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475262151 | ||||||||
FaxNumber: | 8475262017 | ||||||||
Practice Location | |||||||||
Address1: | 15 TOWER CT | ||||||||
Address2: | SUITE 255 | ||||||||
City: | GURNEE | ||||||||
State: | IL | ||||||||
PostalCode: | 600313336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475262151 | ||||||||
FaxNumber: | 8475262017 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2017 | ||||||||
LastUpdateDate: | 04/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BELLUCCI | ||||||||
AuthorizedOfficialFirstName: | JASON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8475262151 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X |   | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.