MEDICARE: LAKE SHORE MEDICAR, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343800000X	Secured Medical Transport (VAN)	001	IL
2	343900000X	Non-emergency Medical Transport (VAN)	001	IL

General Provider Information

NPI Number	:	1275733958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SHORE MEDICAR, INC.

Provider Business Mailing Address
First Line	:	2640 W TOUHY AVE
Second Line	:	SUITE 211
City	:	CHICAGO
State	:	IL
Zip	:	60645-3198
Country	:	US
Telephone Number	:	773-973-4811
Fax Number	:	773-973-2614

Provider Business Practice Location Address
First Line	:	2640 W TOUHY AVE
Second Line	:	SUITE 211
City	:	CHICAGO
State	:	IL
Zip	:	60645-3198
Country	:	US
Telephone Number	:	773-973-4811
Fax Number	:	773-973-2614

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARIA C PAMATMAT
Credential	:
Telephone Number	:	773-973-4811

Provider Enumeration Date	:	07/20/2007
Last Update Date	:	07/21/2022

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