NPIMap

Organization Active NPI

Family Medicine Specialists of Round Lake Incorporated S C

  • Family Medicine Physician
  • Round Lake Beach, IL
National Provider Identifier
1740515253
Registry record updated Oct 9, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
036083207 Issued in IL
Legal business name
FAMILY MEDICINE SPECIALISTS OF ROUND LAKE INCORPORATED S C
Practice address
2680 Route 83
Round Lake Beach, IL 60073
Phone
(224) 372-7780
Fax
(224) 372-7782
NPI assigned
Oct 16, 2009
Last updated
Oct 9, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 9, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jason Bellucci
Title
Cfo
Phone
(847) 526-2151

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 036083207 IL Primary

Addresses

Primary practice location

2680 Route 83
Round Lake Beach, IL 60073

Mailing address

PO Box 6037
Wauconda, IL 60084-2452
Phone (847) 526-2151

Other names 1

  • FAMILY MEDICINE SPECIALISTS INCORPORATED Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100106000383 IL Part B Supplier - Clinic/Group Practice 6002957511 Receives reassigned benefits from 30 practitioners
Practice locations: Round Lake Beach, IL; Zion, IL

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D1105255Family Medicine Specialists of Round Lake2680 Route 83, Round Lake Beach, IL 60073Certificate of waiverSep 20, 2027

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 30

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 30

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1255651200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1728432000000",
    "number": "1740515253",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 6037",
            "city": "WAUCONDA",
            "state": "IL",
            "postal_code": "600842452",
            "telephone_number": "847-526-2151",
            "fax_number": "847-526-2017"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2680 ROUTE 83",
            "city": "ROUND LAKE BEACH",
            "state": "IL",
            "postal_code": "60073",
            "telephone_number": "224-372-7780",
            "fax_number": "224-372-7782"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY MEDICINE SPECIALISTS OF ROUND LAKE INCORPORATED S C",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-10-16",
        "last_updated": "2024-10-09",
        "certification_date": "2024-10-09",
        "status": "A",
        "authorized_official_last_name": "BELLUCCI",
        "authorized_official_first_name": "JASON",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "847-526-2151",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "036083207",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "FAMILY MEDICINE SPECIALISTS INCORPORATED",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Round Lake Beach, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.