Provider Demographics
NPI:1528094869
Name:LAKESHORE WOMENS HEALTH SPECIALISTS SC
Entity type:Organization
Organization Name:LAKESHORE WOMENS HEALTH SPECIALISTS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAKOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-472-1444
Mailing Address - Street 1:1460 N HALSTED
Mailing Address - Street 2:SUITE 503
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2613
Mailing Address - Country:US
Mailing Address - Phone:773-472-1444
Mailing Address - Fax:773-472-4424
Practice Address - Street 1:1460 N HALSTED
Practice Address - Street 2:SUITE 503
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2613
Practice Address - Country:US
Practice Address - Phone:773-472-1444
Practice Address - Fax:773-472-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1620171OtherBLUE CROSS BLUE SHIELD