Healthcare Provider Details

I. General information

NPI: 1649355793
Provider Name (Legal Business Name): FAMILY MEDICAL CENTER OF LAGRANGE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 S WILLOW SPRINGS ROAD SUITE 300
LAGRANGE IL
60525
US

IV. Provider business mailing address

5201 S WILLOW SPRINGS ROAD SUITE 300
LAGRANGE IL
60525
US

V. Phone/Fax

Practice location:
  • Phone: 708-482-8088
  • Fax: 708-482-9034
Mailing address:
  • Phone: 708-482-8088
  • Fax: 708-482-9034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL FRANCIS DUPONT
Title or Position: VICE PRESIDENT PHYSICIAN
Credential: MD
Phone: 708-482-8088