Healthcare Provider Details

I. General information

NPI: 1265833958
Provider Name (Legal Business Name): LAKE COUNTY INTERNAL MEDICINE ASSOCIATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 KILDEER CT
LONG GROVE IL
60047-5052
US

IV. Provider business mailing address

5911 KILDEER CT
LONG GROVE IL
60047-5052
US

V. Phone/Fax

Practice location:
  • Phone: 847-672-8373
  • Fax: 815-464-9285
Mailing address:
  • Phone: 847-672-8373
  • Fax: 815-464-9285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIUSZ MILEJCZYK
Title or Position: M.D.
Credential: M.D.
Phone: 847-596-7426