=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265611438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PHYSICIANS OF LAKEVIEW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2007
-----------------------------------------------------
Last Update Date | 09/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3002 N ASHLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-244-0441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3002 N ASHLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-244-0441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SARA BRAUNSTEIN BRAUNSTEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-244-0485
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------