Provider Demographics
NPI:1376573527
Name:INTERNAMED, P.C.
Entity Type:Organization
Organization Name:INTERNAMED, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGEI
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIPOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-608-7542
Mailing Address - Street 1:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60121-5478
Mailing Address - Country:US
Mailing Address - Phone:847-608-7542
Mailing Address - Fax:847-608-9812
Practice Address - Street 1:1975 LIN LOR LN
Practice Address - Street 2:SUITE 285
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4902
Practice Address - Country:US
Practice Address - Phone:847-608-7542
Practice Address - Fax:847-608-9812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065857207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065857Medicaid
IL0004527746OtherBLUE SHIELD
IL=========OtherTIN
IL0004527746OtherBLUE SHIELD
IL902210Medicare PIN