Provider Demographics
NPI:1649355793
Name:FAMILY MEDICAL CENTER OF LAGRANGE LTD
Entity type:Organization
Organization Name:FAMILY MEDICAL CENTER OF LAGRANGE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:DUPONT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-482-8088
Mailing Address - Street 1:5201 S WILLOW SPRINGS ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAGRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525
Mailing Address - Country:US
Mailing Address - Phone:708-482-8088
Mailing Address - Fax:708-482-9034
Practice Address - Street 1:5201 S WILLOW SPRINGS ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:LAGRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525
Practice Address - Country:US
Practice Address - Phone:708-482-8088
Practice Address - Fax:708-482-9034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL397950Medicare ID - Type Unspecified