Healthcare Provider Details

I. General information

NPI: 1063406601
Provider Name (Legal Business Name): FAMILY MEDICINE SPECIALISTS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 W LIBERTY ST
WAUCONDA IL
60084-3479
US

IV. Provider business mailing address

PO BOX 6037
WAUCONDA IL
60084-6037
US

V. Phone/Fax

Practice location:
  • Phone: 847-526-2151
  • Fax: 847-526-2017
Mailing address:
  • Phone: 847-526-2151
  • Fax: 847-526-2017

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: JASON C BELLUCCI
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 847-526-2151