Provider Demographics
NPI:1689673055
Name:LAKE SHORE PATHOLOGISTS SC
Entity Type:Organization
Organization Name:LAKE SHORE PATHOLOGISTS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:HIMANI
Authorized Official - Middle Name:D
Authorized Official - Last Name:DALIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-360-3000
Mailing Address - Street 1:520 E. 22ND STREET
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148
Mailing Address - Country:US
Mailing Address - Phone:630-874-2542
Mailing Address - Fax:
Practice Address - Street 1:1324 N SHERIDAN RD
Practice Address - Street 2:VISTA MEDICAL CENTER EAST
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2161
Practice Address - Country:US
Practice Address - Phone:847-360-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDB7421Medicare PIN
IL209177Medicare PIN