Provider Demographics
NPI:1417145301
Name:SURGEONS OF LAKE COUNTY LLC
Entity Type:Organization
Organization Name:SURGEONS OF LAKE COUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-816-7495
Mailing Address - Street 1:1870 W WINCHESTER RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5358
Mailing Address - Country:US
Mailing Address - Phone:847-816-7495
Mailing Address - Fax:847-816-7497
Practice Address - Street 1:1870 W WINCHESTER RD
Practice Address - Street 2:SUITE 112
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5358
Practice Address - Country:US
Practice Address - Phone:847-816-7495
Practice Address - Fax:847-816-7497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109065208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty