Provider Demographics
NPI:1326056276
Name:LAKE SHORE ADULT & GERIATRIC MEDICINE, LTD
Entity Type:Organization
Organization Name:LAKE SHORE ADULT & GERIATRIC MEDICINE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:VEXELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-649-6565
Mailing Address - Street 1:150 E HURON STREET
Mailing Address - Street 2:SUITE 805
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2912
Mailing Address - Country:US
Mailing Address - Phone:312-649-6565
Mailing Address - Fax:312-649-9842
Practice Address - Street 1:150 E HURON STREET
Practice Address - Street 2:SUITE 805
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2912
Practice Address - Country:US
Practice Address - Phone:312-649-6565
Practice Address - Fax:312-649-9842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208984Medicare PIN