Provider Demographics
NPI:1639204613
Name:LAKE STREET FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:LAKE STREET FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOECHER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-516-0434
Mailing Address - Street 1:220 E LAKE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2887
Mailing Address - Country:US
Mailing Address - Phone:630-516-0434
Mailing Address - Fax:630-516-0419
Practice Address - Street 1:220 E LAKE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2887
Practice Address - Country:US
Practice Address - Phone:630-516-0434
Practice Address - Fax:630-516-0419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212461Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER