Provider Demographics
NPI:1700925583
Name:LAKE SHORE OB GYN OF DECATUR S C
Entity type:Organization
Organization Name:LAKE SHORE OB GYN OF DECATUR S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEL
Authorized Official - Middle Name:SAMY
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-429-4119
Mailing Address - Street 1:1770 E LAKE SHORE DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3832
Mailing Address - Country:US
Mailing Address - Phone:217-429-4119
Mailing Address - Fax:217-429-0108
Practice Address - Street 1:741 W PERSHING RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1634
Practice Address - Country:US
Practice Address - Phone:217-429-4119
Practice Address - Fax:217-429-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
634112OtherHEALTH LINK
IL05832038OtherBLUE CROSS BLUE SHIELD
IL036110172Medicaid
IL05832038OtherBLUE CROSS BLUE SHIELD
ILDE3439Medicare Oscar/Certification
ILH99460Medicare UPIN