Provider Demographics
NPI:1275659187
Name:LAKE SHORE GASTROENTEROLOGY
Entity Type:Organization
Organization Name:LAKE SHORE GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:REID
Authorized Official - Last Name:GLAWS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:847-244-2960
Mailing Address - Street 1:20 TOWER CT
Mailing Address - Street 2:SUITE C
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5711
Mailing Address - Country:US
Mailing Address - Phone:847-244-2960
Mailing Address - Fax:847-244-2986
Practice Address - Street 1:9700 KENTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1259
Practice Address - Country:US
Practice Address - Phone:847-433-9840
Practice Address - Fax:847-433-9842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL632380Medicare ID - Type Unspecified