Provider Demographics
NPI:1629063391
Name:LAKE HEART SPECIALISTS
Entity Type:Organization
Organization Name:LAKE HEART SPECIALISTS
Other - Org Name:DRS. JAJEH & KOCH SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FAHD
Authorized Official - Middle Name:
Authorized Official - Last Name:JAJEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-360-8440
Mailing Address - Street 1:35 TOWER CT
Mailing Address - Street 2:SUITE F
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5712
Mailing Address - Country:US
Mailing Address - Phone:847-360-8440
Mailing Address - Fax:847-360-8468
Practice Address - Street 1:35 TOWER CT
Practice Address - Street 2:SUITE F
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5712
Practice Address - Country:US
Practice Address - Phone:847-360-8440
Practice Address - Fax:847-360-8468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
763341Medicare ID - Type Unspecified