1558453738 NPI number — LAKE SHORE CARDIOLOGY GROUP, LTD.

Table of content: (NPI 1558453738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558453738 NPI number — LAKE SHORE CARDIOLOGY GROUP, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE SHORE CARDIOLOGY GROUP, LTD.
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:
Provider Other Organization Name Type Code:
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:
1558453738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
233 E ERIE ST
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60611-2926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-854-0031
Provider Business Mailing Address Fax Number:
312-255-1245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 E ERIE ST
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60611-2926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-854-0031
Provider Business Practice Location Address Fax Number:
312-255-1245
Provider Enumeration Date:
09/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KOENIGSBERG
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
312-854-0031

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1617522 . This is a "BC BS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 234690 . This is a "HARMONY HEALTH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CL4625 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".