Provider Demographics
NPI:1841247608
Name:NORTHERN LAKE MEDICAL, LTD.
Entity type:Organization
Organization Name:NORTHERN LAKE MEDICAL, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-587-0115
Mailing Address - Street 1:45 TOWER CT
Mailing Address - Street 2:SUITE C
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3376
Mailing Address - Country:US
Mailing Address - Phone:847-623-3200
Mailing Address - Fax:847-623-9168
Practice Address - Street 1:45 TOWER CT
Practice Address - Street 2:SUITE C
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3376
Practice Address - Country:US
Practice Address - Phone:847-623-3200
Practice Address - Fax:847-623-9168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========-60031Medicaid
IL381700Medicare ID - Type Unspecified