MEDICARE: LAKE SHORE PODIATRY CENTER, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	IL
2	213ES0131X	Foot Surgery Podiatrist	IL
3	213EP1101X	Primary Podiatric Medicine Podiatrist	IL
4	213EP0504X	Public Medicine Podiatrist	IL
5	213E00000X	Podiatrist	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	216-22095	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1679670905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SHORE PODIATRY CENTER, LLC

Provider Business Mailing Address
First Line	:	9933 S WESTERN AVE
Second Line	:	SUITE 102
City	:	CHICAGO
State	:	IL
Zip	:	60643-1810
Country	:	US
Telephone Number	:	773-233-3800
Fax Number	:	773-233-2513

Provider Business Practice Location Address
First Line	:	2143 W WELLINGTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-8268
Country	:	US
Telephone Number	:	773-871-2250
Fax Number	:	773-697-0134

Authorized Official
Title or Position	:	MEDICAL DIRECTOR & CEO
Name	:	DR. FORTUNEE MASSUDA
Credential	:	DPM
Telephone Number	:	773-233-0590

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	02/14/2008

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