Provider Demographics
NPI:1275733958
Name:LAKE SHORE MEDICAR, INC.
Entity Type:Organization
Organization Name:LAKE SHORE MEDICAR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PAMATMAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-973-4811
Mailing Address - Street 1:2640 W TOUHY AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-3198
Mailing Address - Country:US
Mailing Address - Phone:773-973-4811
Mailing Address - Fax:773-973-2614
Practice Address - Street 1:2640 W TOUHY AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-3198
Practice Address - Country:US
Practice Address - Phone:773-973-4811
Practice Address - Fax:773-973-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001343800000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid