Healthcare Provider Details

I. General information

NPI: 1114208642
Provider Name (Legal Business Name): LAKE IMMEDIATE CARE & CLINIC S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 W STATE RD STE D
ISLAND LAKE IL
60042-8438
US

IV. Provider business mailing address

452 W STATE RD STE D
ISLAND LAKE IL
60042-8438
US

V. Phone/Fax

Practice location:
  • Phone: 847-519-1061
  • Fax:
Mailing address:
  • Phone: 847-519-1061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036113328
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036107391
License Number StateIL

VIII. Authorized Official

Name: DR. EBERECHUKWU IBE
Title or Position: PRESIDENT
Credential: M.D
Phone: 708-606-7219