MEDICARE: ENT CONSULTANTS OF LAKE COUNTY

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	207Y00000X	Otolaryngology Physician	042-002811	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811982408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENT CONSULTANTS OF LAKE COUNTY

Provider Business Mailing Address
First Line	:	755 S MILWAUKEE AVE
Second Line	:	STE 181
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048
Country	:	US
Telephone Number	:	847-816-1228
Fax Number	:	847-816-1262

Provider Business Practice Location Address
First Line	:	755 S MILWAUKEE AVE
Second Line	:	STE 181
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-3253
Country	:	US
Telephone Number	:	847-816-1228
Fax Number	:	847-816-1262

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. STACEY M WILCOX
Credential	:
Telephone Number	:	847-816-1228

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	10/05/2012

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Directions to “ENT CONSULTANTS OF LAKE COUNTY ” Practice Location

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