Basic Information
Provider Information
NPI: 1295945335
EntityType: 2
ReplacementNPI:  
OrganizationName: LAKESHORE ANESTHESIA LTD
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Mailing Information
Address1: 1165 N CLARK ST STE 700
Address2:  
City: CHICAGO
State: IL
PostalCode: 606102821
CountryCode: US
TelephoneNumber: 3128096500
FaxNumber: 3128096501
Practice Location
Address1: 7101 W HIGGINS AVE
Address2:  
City: CHICAGO
State: IL
PostalCode: 606561903
CountryCode: US
TelephoneNumber: 3128096500
FaxNumber: 3128096501
Other Information
ProviderEnumerationDate: 05/23/2007
LastUpdateDate: 03/17/2018
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: ROCK
AuthorizedOfficialFirstName: MICHAEL
AuthorizedOfficialMiddleName: H
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 3128096500
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000X042619027ILN193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiology 
208VP0014X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine

ID Information
IDTypeStateIssuerDescription
761508000101ILMEDICARE NSCOTHER


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