1205952686 NPI number — LAKE SHORE GASTROENTEROLOGY

Table of content: (NPI 1205952686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205952686 NPI number — LAKE SHORE GASTROENTEROLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE SHORE GASTROENTEROLOGY
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:
1205952686
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 TOWER CT
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
GURNEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60031-5711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-244-2960
Provider Business Mailing Address Fax Number:
847-244-2986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
806 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
HIGHLAND PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60035-5613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-433-9840
Provider Business Practice Location Address Fax Number:
847-433-9842
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROSENBERG
Authorized Official First Name:
FRED
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-244-2960

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , 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)





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