Healthcare Provider Details

I. General information

NPI: 1093703688
Provider Name (Legal Business Name): LAKE SHORE MEDICAL ASSOCIATES, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2005
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W DIVISION ST STE 116
CHICAGO IL
60622-3093
US

IV. Provider business mailing address

2734 N LINCOLN AVE
CHICAGO IL
60614-1321
US

V. Phone/Fax

Practice location:
  • Phone: 773-525-7720
  • Fax: 773-525-9199
Mailing address:
  • Phone: 773-525-7720
  • Fax: 773-525-9199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VIJAYALAKSHMI AREKAPUDI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-525-7720