Provider Demographics
NPI:1497079636
Name:FAMILY MEDICINE SPECIALISTS, INC
Entity Type:Organization
Organization Name:FAMILY MEDICINE SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLUCI-JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-526-2151
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:888-652-3017
Practice Address - Street 1:431 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-2452
Practice Address - Country:US
Practice Address - Phone:847-526-2151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY MEDICINE SPECIALISTS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-17
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF26238Medicare UPIN