Provider Demographics
NPI:1386807006
Name:LAKESIDE NEPHROLOGY, LTD.
Entity type:Organization
Organization Name:LAKESIDE NEPHROLOGY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-581-0110
Mailing Address - Street 1:9801 WOODS DR
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1074
Mailing Address - Country:US
Mailing Address - Phone:847-581-0110
Mailing Address - Fax:847-581-1768
Practice Address - Street 1:9332 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1309
Practice Address - Country:US
Practice Address - Phone:847-581-0110
Practice Address - Fax:847-581-1768
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESIDE NEPHROLOGY, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-02
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36097354174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG86300Medicare UPIN