Provider Demographics
NPI:1437236015
Name:GRAYSLAKE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:GRAYSLAKE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-548-8269
Mailing Address - Street 1:900 TECHNOLOGY WAY STE 230
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5364
Mailing Address - Country:US
Mailing Address - Phone:847-548-8269
Mailing Address - Fax:847-548-8969
Practice Address - Street 1:900 TECHNOLOGY WAY STE 230
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5364
Practice Address - Country:US
Practice Address - Phone:847-548-8269
Practice Address - Fax:847-548-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1144208554OtherNPI/INDIVIDUAL
ILG53569Medicare UPIN