1144418633 NPI number — LAKEFRONT MEDICAL ASSOCIATES LLC

Table of content: (NPI 1144418633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144418633 NPI number — LAKEFRONT MEDICAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEFRONT MEDICAL ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VANGUARD MEDICAL GROUP - LAKEFRONT
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144418633
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 BURTON HILLS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37215-6197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-665-6000
Provider Business Mailing Address Fax Number:
615-665-6184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4646 N MARINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60640-5759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-564-5102
Provider Business Practice Location Address Fax Number:
773-564-5101
Provider Enumeration Date:
10/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ARMIN
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
VP OF GOVT PROGRAMS, TENET
Authorized Official Telephone Number:
818-436-2267

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1638544 . This is a "BCBS - IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".