Provider Demographics
NPI:1740515253
Name:FAMILY MEDICINE SPECIALISTS OF ROUND LAKE INCORPORATED S C
Entity type:Organization
Organization Name:FAMILY MEDICINE SPECIALISTS OF ROUND LAKE INCORPORATED S C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-526-2151
Mailing Address - Street 1:PO BOX 6037
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-2452
Mailing Address - Country:US
Mailing Address - Phone:847-526-2151
Mailing Address - Fax:847-526-2017
Practice Address - Street 1:2680 ROUTE 83
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073
Practice Address - Country:US
Practice Address - Phone:224-372-7780
Practice Address - Fax:224-372-7782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2778Medicare PIN