Provider Demographics
NPI:1003893017
Name:FAMILY HEALTH SERVICES S.C.
Entity Type:Organization
Organization Name:FAMILY HEALTH SERVICES S.C.
Other - Org Name:GLEN FLORA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMPO
Authorized Official - Middle Name:E
Authorized Official - Last Name:SUESCUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-249-3322
Mailing Address - Street 1:935 GLEN FLORA AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085
Mailing Address - Country:US
Mailing Address - Phone:847-249-3322
Mailing Address - Fax:847-249-3381
Practice Address - Street 1:935 GLEN FLORA AVE
Practice Address - Street 2:STE 201
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:847-249-3322
Practice Address - Fax:847-249-3381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099235Medicaid
BS6129995OtherDEA
IL036099235Medicaid
BS6129995OtherDEA