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NPI Code Detail

MEDICARE: LAKE SHORE PODIATRY CENTER, LLC

MEDICARE: LAKE SHORE PODIATRY CENTER, 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
1213E00000XPodiatristIL
2213ES0131XFoot Surgery PodiatristIL
3213EP1101XPrimary Podiatric Medicine PodiatristIL
4213EP0504XPublic Medicine PodiatristIL
5213ES0103XFoot & Ankle Surgery PodiatristIL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1216-22095OTHERILBCBS

General Provider Information

NPI Number : 1366548018
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKE SHORE PODIATRY CENTER, LLC
Provider Business Mailing Address
First Line : 9933 S WESTERN AVE
Second Line : SUITE 102
City : CHICAGO
State : IL
Zip : 60643-1810
Country : US
Telephone Number : 773-233-3800
Fax Number : 773-233-2513
Provider Business Practice Location Address
First Line : 4733 N DAMEN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60625-1442
Country : US
Telephone Number : 773-871-2250
Fax Number : 773-697-0134
Authorized Official
Title or Position : MEDICAL DIRECTOR & CEO
Name : DR. FORTUNEE MASSUDA
Credential : DPM
Telephone Number : 773-233-3800
Provider Enumeration Date : 09/16/2006
Last Update Date : 07/17/2008

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Directions to “LAKE SHORE PODIATRY CENTER, LLC ” Practice Location

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