Provider Demographics
NPI:1245761295
Name:LAKE COUNTY PRIMARY CARE S.C.
Entity Type:Organization
Organization Name:LAKE COUNTY PRIMARY CARE S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-526-2151
Mailing Address - Street 1:PO BOX 6037
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-6037
Mailing Address - Country:US
Mailing Address - Phone:847-526-2151
Mailing Address - Fax:847-526-2017
Practice Address - Street 1:15 TOWER CT
Practice Address - Street 2:SUITE 255
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3336
Practice Address - Country:US
Practice Address - Phone:847-526-2151
Practice Address - Fax:847-526-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-22
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty