Provider Demographics
NPI:1134280753
Name:LAKE COUNTY PHYSICIANS ASSOCIATION
Entity Type:Organization
Organization Name:LAKE COUNTY PHYSICIANS ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR FULL SERVICE UNIT
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WELTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-490-6752
Mailing Address - Street 1:630 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4026
Practice Address - Country:US
Practice Address - Phone:815-490-6752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization