Provider Demographics
NPI:1114179215
Name:LAKE SHORE FOOT & ANKLE, PC
Entity Type:Organization
Organization Name:LAKE SHORE FOOT & ANKLE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-433-4441
Mailing Address - Street 1:2623 N HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2393
Mailing Address - Country:US
Mailing Address - Phone:773-477-3668
Mailing Address - Fax:773-871-1244
Practice Address - Street 1:767 PARK AVE W
Practice Address - Street 2:SUITE 130
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2400
Practice Address - Country:US
Practice Address - Phone:847-432-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004996213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004996Medicaid
IL213199Medicare PIN
IL4870660003Medicare NSC