| Lake Shore Adult & Geriatric Medicine, Ltd | |
|
150 E Huron Street Suite 805 Chicago IL 60611-2912 | |
| (312) 649-6565 | |
| (312) 649-9842 |
| Full Name | Lake Shore Adult & Geriatric Medicine, Ltd |
|---|---|
| Speciality | Family Medicine |
| Location | 150 E Huron Street, Chicago, Illinois |
| Authorized Official Name and Position | Mark Vexelman (PRESIDENT) |
| Authorized Official Contact | 3126496565 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lake Shore Adult & Geriatric Medicine, Ltd 150 E Huron Street Suite 805 Chicago IL 60611-2912 Ph: (312) 649-6565 | Lake Shore Adult & Geriatric Medicine, Ltd 150 E Huron Street Suite 805 Chicago IL 60611-2912 Ph: (312) 649-6565 |
| NPI Number | 1326056276 |
|---|---|
| Provider Enumeration Date | 08/04/2006 |
| Last Update Date | 04/09/2010 |
| Medicare PECOS PAC ID | 6507765443 |
|---|---|
| Medicare Enrollment ID | O20040108000700 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1326056276 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 036095873 (Illinois) | Primary |
| Provider Name | Mark Vexelman |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1700896750 PECOS PAC ID: 5496654386 Enrollment ID: I20040108000997 |
| Provider Name | Judith Ann Mrvan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1962649335 PECOS PAC ID: 6507161684 Enrollment ID: I20200311001850 |
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