MEDICARE: ROUND LAKE FAMILY PHYSICIANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0491507812	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1427044759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROUND LAKE FAMILY PHYSICIANS

Provider Business Mailing Address
First Line	:	707 RAILROAD AVE
Second Line	:
City	:	ROUND LAKE
State	:	IL
Zip	:	60073-3237
Country	:	US
Telephone Number	:	847-546-8777
Fax Number	:	847-546-8779

Provider Business Practice Location Address
First Line	:	707 RAILROAD AVE
Second Line	:
City	:	ROUND LAKE
State	:	IL
Zip	:	60073-3237
Country	:	US
Telephone Number	:	847-546-8777
Fax Number	:	847-546-8779

Authorized Official
Title or Position	:	GENERAL PARTNER
Name	:	JAI JUNG NHO
Credential	:	M.D.
Telephone Number	:	847-546-8777

Provider Enumeration Date	:	09/22/2005
Last Update Date	:	08/04/2010

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Directions to “ROUND LAKE FAMILY PHYSICIANS ” Practice Location

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