Provider Demographics
NPI:1306142872
Name:LAKE SHORE PLASTIC SURGERY
Entity type:Organization
Organization Name:LAKE SHORE PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-202-9000
Mailing Address - Street 1:60 E DELAWARE PL
Mailing Address - Street 2:15TH FL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1998
Mailing Address - Country:US
Mailing Address - Phone:312-202-9000
Mailing Address - Fax:
Practice Address - Street 1:60 E DELAWARE PL
Practice Address - Street 2:15TH FL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1998
Practice Address - Country:US
Practice Address - Phone:312-202-9000
Practice Address - Fax:312-202-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092789174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG85472Medicare UPIN