Provider Demographics
NPI:1538356233
Name:LAKE SHORE THERAPY CENTER, INC.
Entity type:Organization
Organization Name:LAKE SHORE THERAPY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIACONESCU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-754-0027
Mailing Address - Street 1:2338 W MORSE AVE
Mailing Address - Street 2:1A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4767
Mailing Address - Country:US
Mailing Address - Phone:773-754-0027
Mailing Address - Fax:773-754-0063
Practice Address - Street 1:2338 W MORSE AVE
Practice Address - Street 2:1 A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-4767
Practice Address - Country:US
Practice Address - Phone:773-754-0027
Practice Address - Fax:773-754-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084312208VP0014X, 2081P2900X
IL070013870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1472Medicare PIN