Provider Demographics
NPI:1003011628
Name:LAKE SHORE PEDIATRICS, LTD
Entity Type:Organization
Organization Name:LAKE SHORE PEDIATRICS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:WHEELER
Authorized Official - Last Name:FONDRIEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-615-4654
Mailing Address - Street 1:900 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1674
Mailing Address - Country:US
Mailing Address - Phone:847-615-4654
Mailing Address - Fax:847-615-1708
Practice Address - Street 1:900 N WESTMORELAND RD
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1674
Practice Address - Country:US
Practice Address - Phone:847-615-4654
Practice Address - Fax:847-615-1708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36065837208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty