Provider Demographics
NPI:1093703688
Name:LAKE SHORE MEDICAL ASSOCIATES, LTD.
Entity Type:Organization
Organization Name:LAKE SHORE MEDICAL ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYALAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:AREKAPUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-525-7720
Mailing Address - Street 1:2734 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1321
Mailing Address - Country:US
Mailing Address - Phone:773-525-7720
Mailing Address - Fax:773-525-9199
Practice Address - Street 1:2222 W DIVISION ST STE 116
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3093
Practice Address - Country:US
Practice Address - Phone:773-525-7720
Practice Address - Fax:773-525-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-08
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD5245-919-2OtherIL CORP FILE NUMBER