MEDICARE: LAKE SHORE ADULT & GERIATRIC MEDICINE, 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	207Q00000X	Family Medicine Physician	036095873	IL

General Provider Information

NPI Number	:	1326056276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SHORE ADULT & GERIATRIC MEDICINE, LTD

Provider Business Mailing Address
First Line	:	150 E HURON STREET
Second Line	:	SUITE 805
City	:	CHICAGO
State	:	IL
Zip	:	60611-2912
Country	:	US
Telephone Number	:	312-649-6565
Fax Number	:	312-649-9842

Provider Business Practice Location Address
First Line	:	150 E HURON STREET
Second Line	:	SUITE 805
City	:	CHICAGO
State	:	IL
Zip	:	60611-2912
Country	:	US
Telephone Number	:	312-649-6565
Fax Number	:	312-649-9842

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK VEXELMAN
Credential	:	MD
Telephone Number	:	312-649-6565

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	04/09/2010

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