Provider Demographics
NPI:1861457558
Name:LAKE VILLA INTERNAL MEDICINE
Entity Type:Organization
Organization Name:LAKE VILLA INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CORRADO
Authorized Official - Middle Name:
Authorized Official - Last Name:UGOLINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-356-2700
Mailing Address - Street 1:50 S MILWAUKEE AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046
Mailing Address - Country:US
Mailing Address - Phone:847-356-2700
Mailing Address - Fax:847-356-2777
Practice Address - Street 1:50 S MILWAUKEE AVE
Practice Address - Street 2:STE 104
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-356-2700
Practice Address - Fax:847-356-2777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F79525Medicare UPIN
IL699870Medicare ID - Type Unspecified