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General NPI Number Information
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NPI Number | 1295197044
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Entity Type | Organization
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Legal Business Name | GREAT LAKES ENDOCRINE AND GENERAL SURGERY LLC
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Dates
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Enumeration Date | 03/22/2016
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Last Update Date | 03/22/2016
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Provider Practice Location Address
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Address Line | 104 CIRCLE RIDGE DR
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City | BURR RIDGE
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State | IL
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Zip | 60527-8379
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Country | US
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Telephone | 570-772-7792
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Fax |
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Provider Business Mailing Address
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Address Line | 104 CIRCLE RIDGE DR
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City | BURR RIDGE
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State | IL
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Zip | 60527-8379
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Country | US
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Telephone | 570-772-7792
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SAMER RODWAN RAJJOUB
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Credential | M.D.
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Telephone | 570-772-7792
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036.098470
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License Number State | IL
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