Provider Demographics
NPI:1881766509
Name:LAKE SHORE MEDICAL SERVICES
Entity type:Organization
Organization Name:LAKE SHORE MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-654-5583
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-654-5583
Mailing Address - Fax:312-654-5580
Practice Address - Street 1:680 N LAKE SHORE DR
Practice Address - Street 2:SUITE 115
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4546
Practice Address - Country:US
Practice Address - Phone:312-654-5583
Practice Address - Fax:312-654-5580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID