Provider Demographics
NPI:1912946120
Name:CHICAGO LAKE SHORE MEDICAL ASSOCIATES,LTD
Entity type:Organization
Organization Name:CHICAGO LAKE SHORE MEDICAL ASSOCIATES,LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARRA
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:312-926-6101
Mailing Address - Street 1:676 N ST CLAIR
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2922
Mailing Address - Country:US
Mailing Address - Phone:312-926-6000
Mailing Address - Fax:312-276-4032
Practice Address - Street 1:676 N ST CLAIR
Practice Address - Street 2:SUITE 2300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2922
Practice Address - Country:US
Practice Address - Phone:312-926-6000
Practice Address - Fax:312-276-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1245580001Medicare NSC