Provider Demographics
NPI:1558453738
Name:LAKE SHORE CARDIOLOGY GROUP, LTD.
Entity Type:Organization
Organization Name:LAKE SHORE CARDIOLOGY GROUP, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:I
Authorized Official - Last Name:KOENIGSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-854-0031
Mailing Address - Street 1:233 E ERIE ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2926
Mailing Address - Country:US
Mailing Address - Phone:312-854-0031
Mailing Address - Fax:312-255-1245
Practice Address - Street 1:233 E ERIE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2926
Practice Address - Country:US
Practice Address - Phone:312-854-0031
Practice Address - Fax:312-255-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1617522OtherBC BS PROVIDER NUMBER
IL234690OtherHARMONY HEALTH
ILCL4625OtherRAILROAD MEDICARE
IL234690OtherHARMONY HEALTH