Provider Demographics
NPI:1841363850
Name:LAKE STREET FAMILY PHYSICIANS SC INC
Entity type:Organization
Organization Name:LAKE STREET FAMILY PHYSICIANS SC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-524-8600
Mailing Address - Street 1:PO BOX 799
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60303
Mailing Address - Country:US
Mailing Address - Phone:708-524-8600
Mailing Address - Fax:708-524-8147
Practice Address - Street 1:1010 W LAKE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301
Practice Address - Country:US
Practice Address - Phone:708-524-8600
Practice Address - Fax:708-524-8147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618366207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDD3406OtherMEDICARE RAILROAD
IL01634822OtherBCBS
IL=========Medicaid
ILDD3406OtherMEDICARE RAILROAD