Provider Demographics
NPI:1578986576
Name:BOUGHTON FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:BOUGHTON FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOFTHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-410-2448
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:CLARENDON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-0278
Mailing Address - Country:US
Mailing Address - Phone:630-410-2448
Mailing Address - Fax:630-410-8327
Practice Address - Street 1:402 W BOUGHTON RD STE F1
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1984
Practice Address - Country:US
Practice Address - Phone:630-410-2448
Practice Address - Fax:630-410-8327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty