Provider Demographics
NPI:1477900785
Name:MEDLOGIC LLC
Entity Type:Organization
Organization Name:MEDLOGIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:C
Authorized Official - Last Name:TYDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-946-8871
Mailing Address - Street 1:5 TIMBERLINE LANE
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015
Mailing Address - Country:US
Mailing Address - Phone:847-946-8871
Mailing Address - Fax:847-906-8597
Practice Address - Street 1:114 WEST ROCKLAND ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-881-6858
Practice Address - Fax:847-906-8597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036139402261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care