Provider Demographics
NPI:1689706111
Name:LAKESHORE CANCER CARE,LTD
Entity Type:Organization
Organization Name:LAKESHORE CANCER CARE,LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-501-3927
Mailing Address - Street 1:1366 WINNETKA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3539
Mailing Address - Country:US
Mailing Address - Phone:847-501-3927
Mailing Address - Fax:847-501-3927
Practice Address - Street 1:5020 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2880
Practice Address - Country:US
Practice Address - Phone:773-506-0900
Practice Address - Fax:773-506-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36516792085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200593Medicare ID - Type Unspecified