NPIMap

Organization Active NPI

Lake Shore Pediatrics, LTD

  • Pediatrics Physician
  • Lake Forest, IL
National Provider Identifier
1003011628
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
License
36065837 Issued in IL
Legal business name
LAKE SHORE PEDIATRICS, LTD
Practice address
900 N Westmoreland Rd
Suite 106
Lake Forest, IL 60045-1674
Phone
(847) 615-4654
Fax
(847) 615-1708
NPI assigned
Jun 15, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Diane Wheeler Fondriest, MDNPI 1568457554
Title
Managing Partner
Phone
(847) 615-4654

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X 36065837 IL Primary

Addresses

Primary practice location

900 N Westmoreland Rd
Suite 106
Lake Forest, IL 60045-1674

Mailing address

900 N Westmoreland Rd
Suite 106
Lake Forest, IL 60045-1674
Phone (847) 615-4654

National Provider Directory

National Provider Directory

Locations

900 N Westmoreland Rd
Ste 106
Lake Forest, IL 60045
Phone (847) 615-0700

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1181865600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1003011628",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "900 N WESTMORELAND RD",
            "address_2": "SUITE 106",
            "city": "LAKE FOREST",
            "state": "IL",
            "postal_code": "600451674",
            "telephone_number": "847-615-4654",
            "fax_number": "847-615-1708"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "900 N WESTMORELAND RD",
            "address_2": "SUITE 106",
            "city": "LAKE FOREST",
            "state": "IL",
            "postal_code": "600451674",
            "telephone_number": "847-615-4654",
            "fax_number": "847-615-1708"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE SHORE PEDIATRICS, LTD",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-15",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "FONDRIEST",
        "authorized_official_first_name": "DIANE",
        "authorized_official_middle_name": "WHEELER",
        "authorized_official_title_or_position": "MANAGING PARTNER",
        "authorized_official_telephone_number": "847-615-4654",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "IL",
            "license": "36065837",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Forest, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.