MEDICARE: RESILIENCE HEALTHCARE- LAKEFRONT MEDICAL ASSOCIATES, 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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1407329782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESILIENCE HEALTHCARE- LAKEFRONT MEDICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	4646 N MARINE DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5759
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 W LAKE ST
Second Line	:
City	:	MELROSE PARK
State	:	IL
Zip	:	60160-4042
Country	:	US
Telephone Number	:	844-533-2464
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MANOJ PRASAD
Credential	:
Telephone Number	:	708-763-6700

Provider Enumeration Date	:	01/09/2019
Last Update Date	:	01/13/2023

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