MEDICARE: LAKESIDE NEPHROLGOY LTD/PRARIE

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	174400000X	Specialist	36-065928	IL

General Provider Information

NPI Number	:	1649433376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE NEPHROLGOY LTD/PRARIE

Provider Business Mailing Address
First Line	:	1717 S WABASH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-1219
Country	:	US
Telephone Number	:	312-913-0110
Fax Number	:	312-913-9154

Provider Business Practice Location Address
First Line	:	1717 S WABASH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-1219
Country	:	US
Telephone Number	:	312-913-0110
Fax Number	:	312-913-9154

Authorized Official
Title or Position	:	PARTNER
Name	:	MR. SHELDON HIRSCH
Credential	:	MD
Telephone Number	:	312-913-0110

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	07/02/2008

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Directions to “LAKESIDE NEPHROLGOY LTD/PRARIE ” Practice Location

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