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General NPI Number Information
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NPI Number | 1699760801
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Entity Type | Organization
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Legal Business Name | LAKE MEDICAL CLINIC SC
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Dates
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Enumeration Date | 09/14/2005
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Last Update Date | 07/17/2015
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Provider Practice Location Address
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Address Line | 564 BARRON BLVD SUITE C
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City | GRAYSLAKE
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State | IL
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Zip | 60030-3355
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Country | US
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Telephone | 847-223-4440
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Fax | 847-223-0149
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Provider Business Mailing Address
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Address Line | PO BOX 263
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City | GRAYSLAKE
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State | IL
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Zip | 60030-0263
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Country | US
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Telephone | 847-223-4440
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Fax | 847-223-0149
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | RAJINDAR SINGH
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Credential | MD
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Telephone | 847-223-4440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 036.053634
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License Number State | IL
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