Basic Information
| Provider Information | |||||||||
| NPI: | 1912946120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHICAGO LAKE SHORE MEDICAL ASSOCIATES,LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 676 N ST CLAIR | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129266000 | ||||||||
| FaxNumber: | 3122764032 | ||||||||
| Practice Location | |||||||||
| Address1: | 676 N ST CLAIR | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129266000 | ||||||||
| FaxNumber: | 3122764032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 07/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | MARRA | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3129266101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 261QS1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.