Provider Demographics
NPI:1265833958
Name:LAKE COUNTY INTERNAL MEDICINE ASSOCIATION LLC
Entity Type:Organization
Organization Name:LAKE COUNTY INTERNAL MEDICINE ASSOCIATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIUSZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MILEJCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-596-7426
Mailing Address - Street 1:5911 KILDEER CT
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5052
Mailing Address - Country:US
Mailing Address - Phone:847-672-8373
Mailing Address - Fax:815-464-9285
Practice Address - Street 1:5911 KILDEER CT
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-5052
Practice Address - Country:US
Practice Address - Phone:847-672-8373
Practice Address - Fax:815-464-9285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDT3947OtherRAILROAD MEDICARE
ILP01139269OtherRAILROAD MEDICARE INDIVIDUAL
ILIL7339Medicare PIN
ILP01139269OtherRAILROAD MEDICARE INDIVIDUAL