Provider Demographics
NPI:1417078858
Name:WESTLAKE MEDICAL ASSOCIATES, LTD
Entity Type:Organization
Organization Name:WESTLAKE MEDICAL ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-984-6452
Mailing Address - Street 1:565 LAKEVIEW PKWY
Mailing Address - Street 2:SUITE 117
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1857
Mailing Address - Country:US
Mailing Address - Phone:847-984-6450
Mailing Address - Fax:847-984-6451
Practice Address - Street 1:565 LAKEVIEW PKWY
Practice Address - Street 2:SUITE 117
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1857
Practice Address - Country:US
Practice Address - Phone:847-984-6450
Practice Address - Fax:847-984-6451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36081366207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4932473OtherBLUE CROSS
IL212066Medicare PIN