1427044759 NPI number — ROUND LAKE FAMILY PHYSICIANS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427044759 NPI number — ROUND LAKE FAMILY PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROUND LAKE FAMILY PHYSICIANS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427044759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 RAILROAD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60073-3237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-546-8777
Provider Business Mailing Address Fax Number:
847-546-8779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 RAILROAD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROUND LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60073-3237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-546-8777
Provider Business Practice Location Address Fax Number:
847-546-8779
Provider Enumeration Date:
09/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NHO
Authorized Official First Name:
JAI
Authorized Official Middle Name:
JUNG
Authorized Official Title or Position:
GENERAL PARTNER
Authorized Official Telephone Number:
847-546-8777

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0491507812 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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