Provider Demographics
NPI:1578612677
Name:LIBERTYVILLE OBGYN S.C.
Entity Type:Organization
Organization Name:LIBERTYVILLE OBGYN S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINCENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:PADOVANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-367-0022
Mailing Address - Street 1:890 GARFIELD AVE
Mailing Address - Street 2:104
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-4723
Mailing Address - Country:US
Mailing Address - Phone:847-367-0022
Mailing Address - Fax:847-680-0696
Practice Address - Street 1:890 GARFIELD AVE
Practice Address - Street 2:104
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-4723
Practice Address - Country:US
Practice Address - Phone:847-367-0022
Practice Address - Fax:847-680-0696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617217207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042617217OtherREGISTERED MEDICAL CORP
IL04923732OtherBCBS
IL04923732OtherBCBS
IL=========Medicaid