Provider Demographics
NPI:1386823540
Name:LAKESHORE INTERVENTIONAL PAIN ASSOCIATES, LLC
Entity Type:Organization
Organization Name:LAKESHORE INTERVENTIONAL PAIN ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-871-0833
Mailing Address - Street 1:1507 WABASH ST
Mailing Address - Street 2:SUITE 400C
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-4300
Mailing Address - Country:US
Mailing Address - Phone:219-871-0833
Mailing Address - Fax:219-871-0836
Practice Address - Street 1:1507 WABASH ST
Practice Address - Street 2:SUITE 400C
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4300
Practice Address - Country:US
Practice Address - Phone:219-871-0833
Practice Address - Fax:219-871-0836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057031A174400000X
01057031A251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232290Medicare PIN