Provider Demographics
NPI:1295197044
Name:GREAT LAKES ENDOCRINE AND GENERAL SURGERY LLC
Entity Type:Organization
Organization Name:GREAT LAKES ENDOCRINE AND GENERAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMER
Authorized Official - Middle Name:RODWAN
Authorized Official - Last Name:RAJJOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-772-7792
Mailing Address - Street 1:104 CIRCLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-8379
Mailing Address - Country:US
Mailing Address - Phone:570-772-7792
Mailing Address - Fax:
Practice Address - Street 1:104 CIRCLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-8379
Practice Address - Country:US
Practice Address - Phone:570-772-7792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.098470208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty