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General NPI Number Information
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NPI Number | 1649433376
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Entity Type | Organization
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Legal Business Name | LAKESIDE NEPHROLGOY LTD/PRARIE
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Dates
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Enumeration Date | 07/02/2008
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Last Update Date | 07/02/2008
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Provider Practice Location Address
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Address Line | 1717 S WABASH AVE
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City | CHICAGO
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State | IL
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Zip | 60616-1219
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Country | US
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Telephone | 312-913-0110
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Fax | 312-913-9154
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Provider Business Mailing Address
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Address Line | 1717 S WABASH AVE
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City | CHICAGO
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State | IL
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Zip | 60616-1219
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Country | US
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Telephone | 312-913-0110
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Fax | 312-913-9154
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Authorized Official
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Title or Position | PARTNER
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Name | MR. SHELDON HIRSCH
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Credential | MD
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Telephone | 312-913-0110
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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 | 36-065928
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License Number State | IL
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