Provider Demographics
NPI:1154456333
Name:LAKESHORE PULMONARY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:LAKESHORE PULMONARY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-850-1990
Mailing Address - Street 1:826 S BELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4257
Mailing Address - Country:US
Mailing Address - Phone:312-850-1990
Mailing Address - Fax:312-455-9365
Practice Address - Street 1:2555 S KING DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2419
Practice Address - Country:US
Practice Address - Phone:312-674-4005
Practice Address - Fax:312-674-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059554207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059554Medicaid
ILL74626Medicare PIN
ILE33406Medicare UPIN