Provider Demographics
NPI:1003301052
Name:LAKE COUNTY ASSOCIATE OF INTERNAL MEDICINE , LLC
Entity type:Organization
Organization Name:LAKE COUNTY ASSOCIATE OF INTERNAL MEDICINE , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAGDALENA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHANCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-367-8297
Mailing Address - Street 1:1880 W WINCHESTER RD STE 106
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5321
Mailing Address - Country:US
Mailing Address - Phone:847-367-8297
Mailing Address - Fax:847-367-4277
Practice Address - Street 1:1880 W WINCHESTER RD STE 106
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5321
Practice Address - Country:US
Practice Address - Phone:847-367-8297
Practice Address - Fax:847-367-4277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2018-08-17
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
IL=========OtherBCBS