Healthcare Provider Details

I. General information

NPI: 1215972799
Provider Name (Legal Business Name): GERALD LASIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N WESTMORELAND RD SUITE 110
LAKE FOREST IL
60045-1674
US

IV. Provider business mailing address

900 N WESTMORELAND RD SUITE 110
LAKE FOREST IL
60045-1674
US

V. Phone/Fax

Practice location:
  • Phone: 847-295-1220
  • Fax: 847-295-1255
Mailing address:
  • Phone: 847-295-1220
  • Fax: 847-295-1255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36038061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: