Provider Demographics
NPI:1497954820
Name:LAKESIDE EYE GROUP, S.C.
Entity Type:Organization
Organization Name:LAKESIDE EYE GROUP, S.C.
Other - Org Name:TAUB EYE CENTER, S.C
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OPHTHALMOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:N
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-553-1818
Mailing Address - Street 1:180 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1900
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7401
Mailing Address - Country:US
Mailing Address - Phone:312-553-1818
Mailing Address - Fax:312-641-5503
Practice Address - Street 1:180 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1900
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7401
Practice Address - Country:US
Practice Address - Phone:312-553-1818
Practice Address - Fax:312-641-5503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042007938174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL369060OtherGROUP NUMBER FOR MEDICARE
IL31601613OtherBLUE CROSS BLUE SHIELD OF
IL036102488Medicaid