Provider Demographics
NPI:1083796122
Name:MEDCOR OF BARRINGTON, PC
Entity Type:Organization
Organization Name:MEDCOR OF BARRINGTON, PC
Other - Org Name:LAKE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:GLIMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-363-9500
Mailing Address - Street 1:PO BOX 3058
Mailing Address - Street 2:
Mailing Address - City:YELLOWSTONE NATIONAL PARK
Mailing Address - State:WY
Mailing Address - Zip Code:82190-3058
Mailing Address - Country:US
Mailing Address - Phone:307-242-7241
Mailing Address - Fax:307-242-7273
Practice Address - Street 1:1 LAKE HOT SPRINGS
Practice Address - Street 2:
Practice Address - City:YELLOWSTONE NAT'L PARK
Practice Address - State:WI
Practice Address - Zip Code:82190
Practice Address - Country:US
Practice Address - Phone:307-242-7241
Practice Address - Fax:307-242-7273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9592Medicare PIN