Provider Demographics
NPI:1841592607
Name:COLE D LUNDQUIST MD SC
Entity Type:Organization
Organization Name:COLE D LUNDQUIST MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:COLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LUNDQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-590-1500
Mailing Address - Street 1:1875 DEMPSTER ST
Mailing Address - Street 2:SUITE 660
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1186
Mailing Address - Country:US
Mailing Address - Phone:847-590-1500
Mailing Address - Fax:847-590-1502
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:SUITE 660
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1186
Practice Address - Country:US
Practice Address - Phone:847-590-1500
Practice Address - Fax:847-590-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056878207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056878Medicaid
IL036056878Medicaid