Provider Demographics
NPI:1346232873
Name:LAKE SHORE PODIATRY CENTER, LLC
Entity Type:Organization
Organization Name:LAKE SHORE PODIATRY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR /CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:FORTUNEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSUDA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-871-2250
Mailing Address - Street 1:9933 S WESTERN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1810
Mailing Address - Country:US
Mailing Address - Phone:773-233-3800
Mailing Address - Fax:773-233-2513
Practice Address - Street 1:3000 N HALSTED ST
Practice Address - Street 2:SUITE 621
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5188
Practice Address - Country:US
Practice Address - Phone:773-871-2250
Practice Address - Fax:773-697-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X, 213EP0504X, 213EP1101X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic MedicineGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216-22095OtherBCBS
IL216-22095OtherBCBS
CH4911Medicare PIN
IL4147780001Medicare NSC