Healthcare Provider Details

I. General information

NPI: 1497748222
Provider Name (Legal Business Name): OB/GYNE ASSOCIATES OF LAKE COUNTY, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 GARFIELD AVE SUITE 200
LIBERTYVILLE IL
60048-4723
US

IV. Provider business mailing address

890 GARFIELD AVE SUITE 200
LIBERTYVILLE IL
60048-4723
US

V. Phone/Fax

Practice location:
  • Phone: 847-549-1818
  • Fax: 847-680-1573
Mailing address:
  • Phone: 847-549-1818
  • Fax: 847-680-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number036067062
License Number StateIL

VIII. Authorized Official

Name: DR. RICHARD MCCLOUD ALLEN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 847-549-1818