Provider Demographics
NPI:1184779373
Name:LAKESIDE NEPHROLOGY, LTD.
Entity type:Organization
Organization Name:LAKESIDE NEPHROLOGY, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-986-0110
Mailing Address - Street 1:1101 S CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4901
Mailing Address - Country:US
Mailing Address - Phone:312-986-0110
Mailing Address - Fax:312-663-1010
Practice Address - Street 1:1101 S CANAL ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4901
Practice Address - Country:US
Practice Address - Phone:312-986-0110
Practice Address - Fax:312-663-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1184779373OtherGROUP NPI