Provider Demographics
NPI:1417093808
Name:OB-GYNE ASSOCIATES OF LAKE FOREST, LTD.
Entity Type:Organization
Organization Name:OB-GYNE ASSOCIATES OF LAKE FOREST, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:HUBBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-234-3250
Mailing Address - Street 1:959 S. WAUKESAN RD
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045
Mailing Address - Country:US
Mailing Address - Phone:847-234-3250
Mailing Address - Fax:847-234-8155
Practice Address - Street 1:959 S. WAUKEGAN RD
Practice Address - Street 2:FLOOR 2
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045
Practice Address - Country:US
Practice Address - Phone:847-234-3250
Practice Address - Fax:847-234-8155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042001387 036084828174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
04915672OtherBCBS
ILCF6069OtherRAILROAD MEDICARE
IL036067565Medicaid
IL036092828Medicaid
IL036084302Medicaid
IL036103613Medicaid
ILCF6069OtherRAILROAD MEDICARE
IL036067565Medicaid
ILI11528Medicare UPIN
ILC37542Medicare UPIN
ILH58544Medicare UPIN