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General NPI Number Information
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NPI Number | 1740515253
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICINE SPECIALISTS OF ROUND LAKE INCORPORATED S C
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Dates
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Enumeration Date | 10/16/2009
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Last Update Date | 10/09/2024
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Provider Practice Location Address
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Address Line | 2680 ROUTE 83
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City | ROUND LAKE BEACH
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State | IL
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Zip | 60073
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Country | US
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Telephone | 224-372-7780
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Fax | 224-372-7782
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Provider Business Mailing Address
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Address Line | PO BOX 6037
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City | WAUCONDA
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State | IL
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Zip | 60084-2452
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Country | US
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Telephone | 847-526-2151
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Fax | 847-526-2017
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Authorized Official
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Title or Position | CFO
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Name | MR. JASON BELLUCCI
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Credential |
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Telephone | 847-526-2151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036083207
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License Number State | IL
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