Basic Information
| Provider Information | |||||||||
| NPI: | 1740515253 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY MEDICINE SPECIALISTS OF ROUND LAKE INCORPORATED S C | ||||||||
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| OtherOrganizationName: | FAMILY MEDICINE SPECIALISTS OF ROUND LAKE INCORPORATED INCORPORATED | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6037 | ||||||||
| Address2: | |||||||||
| City: | WAUCONDA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600842452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475262151 | ||||||||
| FaxNumber: | 8475262017 | ||||||||
| Practice Location | |||||||||
| Address1: | 2680 ROUTE 83 | ||||||||
| Address2: | |||||||||
| City: | ROUND LAKE BEACH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2243727780 | ||||||||
| FaxNumber: | 2243727782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2009 | ||||||||
| LastUpdateDate: | 07/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | BELLUCCI | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8475262151 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036083207 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.