Provider Demographics
NPI:1649433376
Name:LAKESIDE NEPHROLGOY LTD/PRARIE
Entity type:Organization
Organization Name:LAKESIDE NEPHROLGOY LTD/PRARIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHELDON
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-913-0110
Mailing Address - Street 1:1717 S WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-1219
Mailing Address - Country:US
Mailing Address - Phone:312-913-0110
Mailing Address - Fax:312-913-9154
Practice Address - Street 1:1717 S WABASH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-1219
Practice Address - Country:US
Practice Address - Phone:312-913-0110
Practice Address - Fax:312-913-9154
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESIDE NEPHROLOGY LTD/LOOP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-065928174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA14008Medicare UPIN