Healthcare Provider Details

I. General information

NPI: 1215063144
Provider Name (Legal Business Name): LAKE SHORE GASTROENTEROLGY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 TOWER CT SUITE C
GURNEE IL
60031
US

IV. Provider business mailing address

20 TOWER CT SUITE C
GURNEE IL
60031
US

V. Phone/Fax

Practice location:
  • Phone: 847-244-6320
  • Fax: 847-244-5095
Mailing address:
  • Phone: 847-244-6320
  • Fax: 847-244-5095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE L. MCKERLIE
Title or Position: ADMINISTRATOR
Credential:
Phone: 847-244-2960