Provider Demographics
NPI:1053941112
Name:LAKESIDE DIGESTION PLLC
Entity type:Organization
Organization Name:LAKESIDE DIGESTION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PALUMBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-900-7562
Mailing Address - Street 1:501 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2815
Mailing Address - Country:US
Mailing Address - Phone:224-900-7562
Mailing Address - Fax:
Practice Address - Street 1:501 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2815
Practice Address - Country:US
Practice Address - Phone:773-319-7319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-16
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861701500OtherNPI NICHOLAS PALUMBO
IL164005341OtherRD LICENSE NICHOLAS PALUMBO
IL248002576OtherBUSINESS LICENSE LAKESIDE DIGESTION