Provider Demographics
NPI:1528237765
Name:LAKESHORE GASTROENTEROLOGY AND LIVER DISEASE INSTITUTE S.C.
Entity type:Organization
Organization Name:LAKESHORE GASTROENTEROLOGY AND LIVER DISEASE INSTITUTE S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEYDARPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-763-8248
Mailing Address - Street 1:PO BOX 14905
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8542
Mailing Address - Country:US
Mailing Address - Phone:708-763-8248
Mailing Address - Fax:708-383-7875
Practice Address - Street 1:1 ERIE COURT
Practice Address - Street 2:SUITE 3100
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60614-8542
Practice Address - Country:US
Practice Address - Phone:708-763-8248
Practice Address - Fax:708-383-7875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336-052655207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091055Medicaid
F47907Medicare UPIN