Healthcare Provider Details

I. General information

NPI: 1639618036
Provider Name (Legal Business Name): PRESENCE LAKESHORE GASTROENTEROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N RIVER RD SUITE 215
DES PLAINES IL
60016-1272
US

IV. Provider business mailing address

150 N RIVER RD SUITE 215
DES PLAINES IL
60016-1272
US

V. Phone/Fax

Practice location:
  • Phone: 847-787-1099
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAUREN LAVAJA
Title or Position: ADMINISTRATOR
Credential:
Phone: 847-787-1099