Healthcare Provider Details

I. General information

NPI: 1174644389
Provider Name (Legal Business Name): LAKESIDE RADIOLOGISTS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 N PAULINA ST
CHICAGO IL
60640-2772
US

IV. Provider business mailing address

PO BOX 218
LANSING IL
60438-0218
US

V. Phone/Fax

Practice location:
  • Phone: 773-271-9040
  • Fax: 773-271-2010
Mailing address:
  • Phone: 219-322-7042
  • Fax: 219-322-4155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. YOUNG S LEE
Title or Position: OWNER
Credential: MD
Phone: 219-322-7042