Healthcare Provider Details

I. General information

NPI: 1497954820
Provider Name (Legal Business Name): LAKESIDE EYE GROUP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 N MICHIGAN AVE SUITE 1900
CHICAGO IL
60601-7401
US

IV. Provider business mailing address

180 N MICHIGAN AVE SUITE 1900
CHICAGO IL
60601-7401
US

V. Phone/Fax

Practice location:
  • Phone: 312-553-1818
  • Fax: 312-641-5503
Mailing address:
  • Phone: 312-553-1818
  • Fax: 312-641-5503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number042007938
License Number StateIL

VIII. Authorized Official

Name: DR. SANJAY N RAO
Title or Position: OPHTHALMOLOGIST
Credential: MD
Phone: 312-553-1818