Provider Demographics
NPI:1417021551
Name:LAKE SHORE MEDICAL CONSULTANTS, S.C.
Entity type:Organization
Organization Name:LAKE SHORE MEDICAL CONSULTANTS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-404-5263
Mailing Address - Street 1:2800 N SHERIDAN RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6156
Mailing Address - Country:US
Mailing Address - Phone:773-404-5263
Mailing Address - Fax:773-404-1867
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6156
Practice Address - Country:US
Practice Address - Phone:773-404-5263
Practice Address - Fax:773-404-1867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0031604330OtherBCBS PROVIDER ID
IL0031604330OtherBCBS PROVIDER ID