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General NPI Number Information
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NPI Number | 1700925583
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Entity Type | Organization
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Legal Business Name | LAKE SHORE OB GYN OF DECATUR S C
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 05/13/2025
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Provider Practice Location Address
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Address Line | 741 W PERSHING RD
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City | DECATUR
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State | IL
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Zip | 62526-1634
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Country | US
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Telephone | 217-429-4119
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Fax | 217-429-0108
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Provider Business Mailing Address
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Address Line | 1770 E LAKE SHORE DR SUITE 303
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City | DECATUR
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State | IL
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Zip | 62521-3832
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Country | US
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Telephone | 217-429-4119
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Fax | 217-429-0108
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Authorized Official
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Title or Position | OWNER
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Name | DR. ADEL SAMY HANNA
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Credential | M.D.
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Telephone | 217-429-4119
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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 |
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License Number State |
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