Provider Demographics
NPI:1083145940
Name:GILLENWATER, LANE
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:GILLENWATER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1658
Mailing Address - Country:US
Mailing Address - Phone:312-234-5600
Mailing Address - Fax:847-535-7203
Practice Address - Street 1:1475 E BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2012
Practice Address - Country:US
Practice Address - Phone:312-926-0106
Practice Address - Fax:312-694-0655
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036151702208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist