Provider Demographics
NPI:1497748222
Name:OB/GYNE ASSOCIATES OF LAKE COUNTY, S.C.
Entity Type:Organization
Organization Name:OB/GYNE ASSOCIATES OF LAKE COUNTY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MCCLOUD
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-549-1818
Mailing Address - Street 1:890 GARFIELD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-4723
Mailing Address - Country:US
Mailing Address - Phone:847-549-1818
Mailing Address - Fax:847-680-1573
Practice Address - Street 1:890 GARFIELD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-4723
Practice Address - Country:US
Practice Address - Phone:847-549-1818
Practice Address - Fax:847-680-1573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067062261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067062Medicaid