Provider Demographics
NPI:1114208642
Name:LAKE IMMEDIATE CARE & CLINIC S C
Entity Type:Organization
Organization Name:LAKE IMMEDIATE CARE & CLINIC S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EBERECHUKWU
Authorized Official - Middle Name:
Authorized Official - Last Name:IBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-606-7219
Mailing Address - Street 1:452 W STATE RD STE D
Mailing Address - Street 2:
Mailing Address - City:ISLAND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60042-8438
Mailing Address - Country:US
Mailing Address - Phone:847-519-1061
Mailing Address - Fax:
Practice Address - Street 1:452 W STATE RD STE D
Practice Address - Street 2:
Practice Address - City:ISLAND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60042-8438
Practice Address - Country:US
Practice Address - Phone:847-519-1061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113328207Q00000X
IL036107391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty