Provider Demographics
NPI:1033295415
Name:FAMILY MEDICINE ASSOCIATES OF LUTHERAN GENERAL S C
Entity Type:Organization
Organization Name:FAMILY MEDICINE ASSOCIATES OF LUTHERAN GENERAL S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBROAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GEISMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-967-9660
Mailing Address - Street 1:7900 N MILWAUKEE AVE
Mailing Address - Street 2:SUITE 233
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3159
Mailing Address - Country:US
Mailing Address - Phone:847-967-9660
Mailing Address - Fax:847-470-9323
Practice Address - Street 1:7900 N MILWAUKEE AVE
Practice Address - Street 2:SUITE 233
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3159
Practice Address - Country:US
Practice Address - Phone:847-967-9660
Practice Address - Fax:847-470-9323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-28
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073437Medicaid
IL01623792OtherBLUE CROSS BLUE SHIELD
IL01623792OtherBLUE CROSS BLUE SHIELD