MEDICARE: LAKESHORE MEDICAL CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center
2	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003861188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESHORE MEDICAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 735044
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-5044
Country	:	US
Telephone Number	:	414-647-6326
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 E LAYTON AVE STE 100
Second Line	:
City	:	SAINT FRANCIS
State	:	WI
Zip	:	53235-6054
Country	:	US
Telephone Number	:	414-744-6589
Fax Number	:

Authorized Official
Title or Position	:	ASSISTANT TREASURER
Name	:	KARA RICHARDSON
Credential	:
Telephone Number	:	704-631-0450

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	10/03/2025

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Directions to “LAKESHORE MEDICAL CLINIC, LLC ” Practice Location

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