=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093703688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE SHORE MEDICAL ASSOCIATES, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2005
-----------------------------------------------------
Last Update Date | 06/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2222 W DIVISION ST STE 116
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-3093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-525-7720
-----------------------------------------------------
Fax | 773-525-9199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2734 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-1321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-525-7720
-----------------------------------------------------
Fax | 773-525-9199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | VIJAYALAKSHMI AREKAPUDI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-525-7720
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------