Provider Demographics
NPI:1740201755
Name:BARIATRIC SPECIALISTS OF ILLINOIS
Entity Type:Organization
Organization Name:BARIATRIC SPECIALISTS OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:LENZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:734-547-1114
Mailing Address - Street 1:135 S PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-7914
Mailing Address - Country:US
Mailing Address - Phone:734-547-1114
Mailing Address - Fax:734-547-1145
Practice Address - Street 1:1625 S STATE ST
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-5907
Practice Address - Country:US
Practice Address - Phone:815-544-1360
Practice Address - Fax:815-547-5394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00432012OtherBCBS PROVIDER NUMBER
00432012OtherBCBS PROVIDER NUMBER