Provider Demographics
NPI:1699760801
Name:LAKE MEDICAL CLINIC SC
Entity type:Organization
Organization Name:LAKE MEDICAL CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RAJINDAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-223-4440
Mailing Address - Street 1:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-0263
Mailing Address - Country:US
Mailing Address - Phone:847-223-4440
Mailing Address - Fax:847-223-0149
Practice Address - Street 1:564 BARRON BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-3355
Practice Address - Country:US
Practice Address - Phone:847-223-4440
Practice Address - Fax:847-223-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.053634207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053634Medicaid
IL735900Medicare PIN
IL036053634Medicaid