Basic Information
| Provider Information | |||||||||
| NPI: | 1154456333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESHORE PULMONARY ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 826 S BELL AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606124257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128501990 | ||||||||
| FaxNumber: | 3124559365 | ||||||||
| Practice Location | |||||||||
| Address1: | 2555 S KING DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126744005 | ||||||||
| FaxNumber: | 3126744001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | BEARD | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3128501990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 036059554 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 036059554 | 05 | IL | MEDICAID |