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General NPI Number Information
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NPI Number | 1497748222
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Entity Type | Organization
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Legal Business Name | OB/GYNE ASSOCIATES OF LAKE COUNTY, S.C.
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Dates
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Enumeration Date | 08/26/2005
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Last Update Date | 07/31/2008
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Provider Practice Location Address
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Address Line | 890 GARFIELD AVE SUITE 200
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-4723
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Country | US
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Telephone | 847-549-1818
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Fax | 847-680-1573
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Provider Business Mailing Address
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Address Line | 890 GARFIELD AVE SUITE 200
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-4723
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Country | US
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Telephone | 847-549-1818
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Fax | 847-680-1573
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. RICHARD MCCLOUD ALLEN
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Credential | M.D.
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Telephone | 847-549-1818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 036067062
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License Number State | IL
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