Provider Demographics
NPI:1558799924
Name:LAKE COUNTY PHYSICAL MEDICINE, S.C.
Entity Type:Organization
Organization Name:LAKE COUNTY PHYSICAL MEDICINE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ATKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-223-3158
Mailing Address - Street 1:15 COMMERCE DR
Mailing Address - Street 2:108
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-7807
Mailing Address - Country:US
Mailing Address - Phone:847-223-3158
Mailing Address - Fax:888-481-4758
Practice Address - Street 1:15 COMMERCE DR
Practice Address - Street 2:108
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-7807
Practice Address - Country:US
Practice Address - Phone:847-223-3158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-23
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.042751207R00000X, 208100000X
208D00000X
IL209-009124363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty