Provider Demographics
NPI:1215004874
Name:GRAYSLAKE FAMILY HEALTH CENTER SC
Entity Type:Organization
Organization Name:GRAYSLAKE FAMILY HEALTH CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:S
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-548-8430
Mailing Address - Street 1:1475 E BELVIDERE RD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2012
Mailing Address - Country:US
Mailing Address - Phone:847-584-5721
Mailing Address - Fax:312-964-1468
Practice Address - Street 1:1475 E BELVIDERE RD
Practice Address - Street 2:SUITE 312
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2012
Practice Address - Country:US
Practice Address - Phone:847-845-7213
Practice Address - Fax:312-694-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098167Medicaid
IL211063Medicare ID - Type Unspecified
IL036098167Medicaid