Provider Demographics
NPI:1396927398
Name:LAKE SHORE SURGICAL ASSOCIATES, LTD.
Entity type:Organization
Organization Name:LAKE SHORE SURGICAL ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:KRAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-641-1150
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-7460
Mailing Address - Country:US
Mailing Address - Phone:312-641-1150
Mailing Address - Fax:312-332-0299
Practice Address - Street 1:111 N WABASH AVE STE 1709
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2989
Practice Address - Country:US
Practice Address - Phone:312-641-1150
Practice Address - Fax:312-332-0299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060787174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL724180Medicare PIN
ILD13433Medicare UPIN
IL950190Medicare PIN