MEDICARE: LAKE SHORE MEDICAL ASSOCIATES LTD

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	207V00000X	Obstetrics & Gynecology Physician
2	261QM2500X	Medical Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D 5245-919-2	OTHER	IL	CORPORATION FILE# ILLINOIS

General Provider Information

NPI Number	:	1104083070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SHORE MEDICAL ASSOCIATES LTD

Provider Business Mailing Address
First Line	:	2734 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1321
Country	:	US
Telephone Number	:	773-525-7720
Fax Number	:	773-525-9199

Provider Business Practice Location Address
First Line	:	2222 W DIVISION ST STE 116
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-3093
Country	:	US
Telephone Number	:	773-525-7720
Fax Number	:	773-525-9199

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VIJAYALAKSHMI AREKAPUDI
Credential	:	M.D.
Telephone Number	:	773-525-7720

Provider Enumeration Date	:	05/19/2008
Last Update Date	:	06/03/2016

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