1497954820 NPI number — LAKESIDE EYE GROUP, S.C.

Table of content: (NPI 1497954820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497954820 NPI number — LAKESIDE EYE GROUP, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE EYE GROUP, S.C.
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:
TAUB EYE CENTER, S.C
Provider Other Organization Name Type Code:
4
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:
1497954820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 N MICHIGAN AVE
Provider Second Line Business Mailing Address:
SUITE 1900
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60601-7401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-553-1818
Provider Business Mailing Address Fax Number:
312-641-5503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 N MICHIGAN AVE
Provider Second Line Business Practice Location Address:
SUITE 1900
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60601-7401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-553-1818
Provider Business Practice Location Address Fax Number:
312-641-5503
Provider Enumeration Date:
07/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAO
Authorized Official First Name:
SANJAY
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OPHTHALMOLOGIST
Authorized Official Telephone Number:
312-553-1818

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  042007938 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 369060 . This is a "GROUP NUMBER FOR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 31601613 . This is a "BLUE CROSS BLUE SHIELD OF" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036102488 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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