Provider Demographics
NPI:1538176722
Name:ORTHOPEDIC CENTER OF LAKE COUNTY PC
Entity type:Organization
Organization Name:ORTHOPEDIC CENTER OF LAKE COUNTY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:SAUL
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-433-3700
Mailing Address - Street 1:625 ROGER WILLIAMS AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-4840
Mailing Address - Country:US
Mailing Address - Phone:847-433-3700
Mailing Address - Fax:847-433-1699
Practice Address - Street 1:625 ROGER WILLIAMS AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-4840
Practice Address - Country:US
Practice Address - Phone:847-433-3700
Practice Address - Fax:847-433-1699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-035962207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04915292OtherBLUECROSS/BLUESHIELD
IL0363650001OtherADMINISTAR
IL483397OtherAETNA
GA202757512OtherRAILROAD MEDICARE
ILP12557OtherMEDICARE PIN
IL036035962Medicaid
IL04915292OtherBLUECROSS/BLUESHIELD
ILD10884Medicare UPIN