Provider Demographics
NPI:1932183365
Name:LAKE FOREST MEDICAL SC
Entity Type:Organization
Organization Name:LAKE FOREST MEDICAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRAUNLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-604-8144
Mailing Address - Street 1:800 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1673
Mailing Address - Country:US
Mailing Address - Phone:847-604-8144
Mailing Address - Fax:847-234-4682
Practice Address - Street 1:800 N WESTMORELAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1673
Practice Address - Country:US
Practice Address - Phone:847-604-8144
Practice Address - Fax:847-234-4682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042618006OtherREGISTERED MEDICAL CORP.