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General NPI Number Information
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NPI Number | 1306142872
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Entity Type | Organization
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Legal Business Name | LAKE SHORE PLASTIC SURGERY
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Dates
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Enumeration Date | 02/01/2011
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Last Update Date | 02/01/2011
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Provider Practice Location Address
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Address Line | 60 E DELAWARE PL 15TH FL
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City | CHICAGO
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State | IL
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Zip | 60611-1998
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Country | US
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Telephone | 312-202-9000
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Fax | 312-202-9002
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Provider Business Mailing Address
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Address Line | 60 E DELAWARE PL 15TH FL
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City | CHICAGO
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State | IL
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Zip | 60611-1998
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Country | US
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Telephone | 312-202-9000
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL ALAN HORN
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Credential | M.D.
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Telephone | 312-202-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 036092789
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License Number State | IL
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