Healthcare Provider Details

I. General information

NPI: 1679670905
Provider Name (Legal Business Name): LAKE SHORE PODIATRY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2143 W WELLINGTON AVE
CHICAGO IL
60618-8268
US

IV. Provider business mailing address

9933 S WESTERN AVE SUITE 102
CHICAGO IL
60643-1810
US

V. Phone/Fax

Practice location:
  • Phone: 773-871-2250
  • Fax: 773-697-0134
Mailing address:
  • Phone: 773-233-3800
  • Fax: 773-233-2513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License Number
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. FORTUNEE MASSUDA
Title or Position: MEDICAL DIRECTOR & CEO
Credential: DPM
Phone: 773-233-0590