MEDICARE: LAKE SHORE THERAPY CENTER, INC.

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	208VP0014X	Interventional Pain Medicine Physician	036-084312	IL
2	225100000X	Physical Therapist	070013870	IL
3	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	036-084312	IL

General Provider Information

NPI Number	:	1538356233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SHORE THERAPY CENTER, INC.

Provider Business Mailing Address
First Line	:	2338 W MORSE AVE
Second Line	:	1A
City	:	CHICAGO
State	:	IL
Zip	:	60645-4767
Country	:	US
Telephone Number	:	773-754-0027
Fax Number	:	773-754-0063

Provider Business Practice Location Address
First Line	:	2338 W MORSE AVE
Second Line	:	1 A
City	:	CHICAGO
State	:	IL
Zip	:	60645-4767
Country	:	US
Telephone Number	:	773-754-0027
Fax Number	:	773-754-0063

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. ELIZA DIACONESCU
Credential	:	M.D.
Telephone Number	:	773-754-0027

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	12/07/2009

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