Provider Demographics
NPI:1861513822
Name:ROUND LAKE MEDICAL SUITES
Entity type:Organization
Organization Name:ROUND LAKE MEDICAL SUITES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-984-6452
Mailing Address - Street 1:2 E ROLLINS RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-3808
Mailing Address - Country:US
Mailing Address - Phone:847-546-9455
Mailing Address - Fax:847-247-2840
Practice Address - Street 1:2 E ROLLINS RD
Practice Address - Street 2:SUITE 108
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-3808
Practice Address - Country:US
Practice Address - Phone:847-546-9455
Practice Address - Fax:847-247-2840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL42618258261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy