Provider Demographics
NPI: | 1760544514 |
---|---|
Name: | LAKE COUNTY PHYSICIANS ASSOCIATION |
Entity Type: | Organization |
Organization Name: | LAKE COUNTY PHYSICIANS ASSOCIATION |
Other - Org Name: | SAINT THERESE PHYSICIANS ASSOCIATION |
Other - Org Type: | Former Legal Business Name |
Authorized Official - Title/Position: | DIRECTOR |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | JOSEPH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LIBERATORE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 847-360-2445 |
Mailing Address - Street 1: | 2615 WASHINGTON ST |
Mailing Address - Street 2: | |
Mailing Address - City: | WAUKEGAN |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60085 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 847-360-2475 |
Mailing Address - Fax: | 847-625-6225 |
Practice Address - Street 1: | 2615 WASHINGTON ST |
Practice Address - Street 2: | |
Practice Address - City: | WAUKEGAN |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60085 |
Practice Address - Country: | US |
Practice Address - Phone: | 847-360-2475 |
Practice Address - Fax: | 847-625-6225 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-12-15 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 171W00000X | Other Service Providers | Contractor | Group - Single Specialty |