Healthcare Provider Details

I. General information

NPI: 1861513822
Provider Name (Legal Business Name): ROUND LAKE MEDICAL SUITES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 E ROLLINS RD SUITE 108
ROUND LAKE BEACH IL
60073-3808
US

IV. Provider business mailing address

2 E ROLLINS RD SUITE 108
ROUND LAKE BEACH IL
60073-3808
US

V. Phone/Fax

Practice location:
  • Phone: 847-546-9455
  • Fax: 847-247-2840
Mailing address:
  • Phone: 847-546-9455
  • Fax: 847-247-2840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number42618258
License Number StateIL

VIII. Authorized Official

Name: SUSAN GOODMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 847-984-6452