Provider Demographics
NPI:1053428581
Name:LAKEVIEW NEUROSURGERY LLC
Entity type:Organization
Organization Name:LAKEVIEW NEUROSURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:DANETTE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-376-6274
Mailing Address - Street 1:246 E JANATA BLVD
Mailing Address - Street 2:STE 135
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148
Mailing Address - Country:US
Mailing Address - Phone:630-376-6274
Mailing Address - Fax:630-376-6279
Practice Address - Street 1:246 E. JANATA BLVD
Practice Address - Street 2:STE 135
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148
Practice Address - Country:US
Practice Address - Phone:630-376-6274
Practice Address - Fax:630-376-6279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111694207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111694Medicaid
IL036111694Medicaid