Healthcare Provider Details

I. General information

NPI: 1912946120
Provider Name (Legal Business Name): CHICAGO LAKE SHORE MEDICAL ASSOCIATES,LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N ST CLAIR SUITE 2300
CHICAGO IL
60611-2922
US

IV. Provider business mailing address

676 N ST CLAIR SUITE 2300
CHICAGO IL
60611-2922
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-6000
  • Fax: 312-276-4032
Mailing address:
  • Phone: 312-926-6000
  • Fax: 312-276-4032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDA D MARRA
Title or Position: PRACTICE MANAGER
Credential: CPC
Phone: 312-926-6101