Provider Demographics
NPI:1376675686
Name:ASSOC PHYSICIANS OF LIBERTYVILLE
Entity Type:Organization
Organization Name:ASSOC PHYSICIANS OF LIBERTYVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-362-9050
Mailing Address - Street 1:1850 W WINCHESTER RD
Mailing Address - Street 2:SUITE220
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5357
Mailing Address - Country:US
Mailing Address - Phone:847-362-9050
Mailing Address - Fax:847-362-9486
Practice Address - Street 1:1850 W WINCHESTER RD
Practice Address - Street 2:SUITE 220
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5357
Practice Address - Country:US
Practice Address - Phone:847-362-9050
Practice Address - Fax:847-362-9486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL630090Medicare ID - Type Unspecified