=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245318567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE COUNTY GENERAL AND VASCULAR SURGICAL ASSOCIATES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2006
-----------------------------------------------------
Last Update Date | 12/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 S GREENLEAF ST STE A
-----------------------------------------------------
City | GURNEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60031-3370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-856-2525
-----------------------------------------------------
Fax | 847-856-1969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 S GREENLEAF ST SUITE A
-----------------------------------------------------
City | GURNEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60031-3370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-856-2525
-----------------------------------------------------
Fax | 847-856-1969
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SHEILA M CASTEEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-856-2525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------