Provider Demographics
NPI:1114102530
Name:LAKE COUNTY PEDIATRICS SC
Entity Type:Organization
Organization Name:LAKE COUNTY PEDIATRICS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:JUCO
Authorized Official - Last Name:TANQUILUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-336-0770
Mailing Address - Street 1:200 S GREENLEAF AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031
Mailing Address - Country:US
Mailing Address - Phone:847-336-0770
Mailing Address - Fax:847-336-0159
Practice Address - Street 1:200 S GREENLEAF AVE
Practice Address - Street 2:SUITE E
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:847-336-0770
Practice Address - Fax:847-336-0159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty