Healthcare Provider Details

I. General information

NPI: 1649433376
Provider Name (Legal Business Name): LAKESIDE NEPHROLGOY LTD/PRARIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S WABASH AVE
CHICAGO IL
60616-1219
US

IV. Provider business mailing address

1717 S WABASH AVE
CHICAGO IL
60616-1219
US

V. Phone/Fax

Practice location:
  • Phone: 312-913-0110
  • Fax: 312-913-9154
Mailing address:
  • Phone: 312-913-0110
  • Fax: 312-913-9154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number36-065928
License Number StateIL

VIII. Authorized Official

Name: MR. SHELDON HIRSCH
Title or Position: PARTNER
Credential: MD
Phone: 312-913-0110