MEDICARE: LAKE COUNTY MEDICAL GROUP SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1588666150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE COUNTY MEDICAL GROUP SC

Provider Business Mailing Address
First Line	:	157 N SEYMOUR AVE
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-2304
Country	:	US
Telephone Number	:	847-566-0300
Fax Number	:	847-566-2818

Provider Business Practice Location Address
First Line	:	157 N SEYMOUR AVE
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-2304
Country	:	US
Telephone Number	:	847-566-0300
Fax Number	:	847-566-2818

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. NINA NEYMAN
Credential	:	M.D.
Telephone Number	:	847-566-0300

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	06/18/2010

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