Healthcare Provider Details

I. General information

NPI: 1841363850
Provider Name (Legal Business Name): LAKE STREET FAMILY PHYSICIANS SC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W LAKE ST SUITE 500
OAK PARK IL
60301
US

IV. Provider business mailing address

PO BOX 799
OAK PARK IL
60303
US

V. Phone/Fax

Practice location:
  • Phone: 708-524-8600
  • Fax: 708-524-8147
Mailing address:
  • Phone: 708-524-8600
  • Fax: 708-524-8147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042618366
License Number StateIL

VIII. Authorized Official

Name: NANCY BELL
Title or Position: PRACTICE MANAGER
Credential:
Phone: 708-524-8600