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General NPI Number Information
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NPI Number | 1528237765
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Entity Type | Organization
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Legal Business Name | LAKESHORE GASTROENTEROLOGY AND LIVER DISEASE INSTITUTE S.C.
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Dates
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Enumeration Date | 02/21/2008
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Last Update Date | 11/26/2014
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Provider Practice Location Address
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Address Line | 1 ERIE COURT SUITE 3100
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City | OAK PARK
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State | IL
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Zip | 60614-8542
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Country | US
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Telephone | 708-763-8248
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Fax | 708-383-7875
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Provider Business Mailing Address
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Address Line | PO BOX 14905
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City | CHICAGO
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State | IL
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Zip | 60614-8542
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Country | US
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Telephone | 708-763-8248
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Fax | 708-383-7875
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Authorized Official
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Title or Position | OWNER
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Name | DR. KAMRAN HEYDARPOUR
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Credential | M.D.
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Telephone | 708-763-8248
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 336-052655
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License Number State | IL
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