Provider Demographics
NPI:1801897434
Name:LAKE COOK SURGICAL ASSOCIATES PC
Entity type:Organization
Organization Name:LAKE COOK SURGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:R
Authorized Official - Last Name:KLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-635-9006
Mailing Address - Street 1:520 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6110
Mailing Address - Country:US
Mailing Address - Phone:630-874-2542
Mailing Address - Fax:
Practice Address - Street 1:1600 DEMPSTER ST
Practice Address - Street 2:SUITE 102
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1109
Practice Address - Country:US
Practice Address - Phone:847-635-9006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL384160Medicare PIN