Provider Demographics
NPI:1871786731
Name:LAKE FOREST INTERNAL MEDICINE, LTD
Entity type:Organization
Organization Name:LAKE FOREST INTERNAL MEDICINE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/ TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:F
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-816-3084
Mailing Address - Street 1:1800 HOLLISTER DR
Mailing Address - Street 2:STE 211
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5263
Mailing Address - Country:US
Mailing Address - Phone:847-816-3084
Mailing Address - Fax:847-816-0031
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:STE 211
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5263
Practice Address - Country:US
Practice Address - Phone:847-816-3084
Practice Address - Fax:847-816-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty