Provider Demographics
NPI:1689165490
Name:EC PHYSICIAN AND WOUND SPECIALIST LLC
Entity Type:Organization
Organization Name:EC PHYSICIAN AND WOUND SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:KERNS
Authorized Official - Last Name:CORMIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-998-0862
Mailing Address - Street 1:625 GLENDALE DR
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-4412
Mailing Address - Country:US
Mailing Address - Phone:847-998-0862
Mailing Address - Fax:
Practice Address - Street 1:1000 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045
Practice Address - Country:US
Practice Address - Phone:847-535-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076935207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty