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General NPI Number Information
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NPI Number | 1730430703
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Entity Type | Organization
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Legal Business Name | LAKESHORE PREMIUM HEALTHCARE, INC
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Dates
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Enumeration Date | 10/01/2012
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Last Update Date | 10/08/2012
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Provider Practice Location Address
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Address Line | 3000 N HALSTED ST SUITE 609
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City | CHICAGO
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State | IL
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Zip | 60657-5188
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Country | US
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Telephone | 949-584-2059
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Fax | 949-679-9174
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Provider Business Mailing Address
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Address Line | 3000 N HALSTED ST SUITE 609
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City | CHICAGO
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State | IL
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Zip | 60657-5188
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Country | US
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Telephone | 949-584-2059
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Fax | 949-679-9174
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. JULIE THOMAS
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Credential | MD
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Telephone | 949-584-2059
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 036-131263
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207RS0012X
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Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
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License Number | 036-131263
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License Number State | IL
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