Healthcare Provider Details

I. General information

NPI: 1528094869
Provider Name (Legal Business Name): LAKESHORE WOMENS HEALTH SPECIALISTS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 N HALSTED SUITE 503
CHICAGO IL
60642-2613
US

IV. Provider business mailing address

1460 N HALSTED SUITE 503
CHICAGO IL
60642-2613
US

V. Phone/Fax

Practice location:
  • Phone: 773-472-1444
  • Fax: 773-472-4424
Mailing address:
  • Phone: 773-472-1444
  • Fax: 773-472-4424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROSE DIAKOS
Title or Position: PARTNER
Credential: MD
Phone: 773-472-1444