NPIMap

Organization Active NPI

Lake Shore Dermatology, LTD.

  • Dermatology Physician
  • Park City, IL
National Provider Identifier
1902977937
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
336067198 Issued in IL
Legal business name
LAKE SHORE DERMATOLOGY, LTD.
Practice address
351 S. Greenleaf
Suite E
Park City, IL 60085
Phone
(847) 680-7100
Fax
(847) 406-3345
NPI assigned
Nov 13, 2006
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. Kavitha Gandhi, M.D.NPI 1629149653
Title
President
Phone
(847) 680-7100

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
Dermatology Physician 207N00000X 336067198 IL Primary

Addresses

Primary practice location

351 S. Greenleaf
Suite E
Park City, IL 60085

Mailing address

351 S. Greenleaf
Suite E
Park City, IL 60085
Phone (847) 680-7100

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050914000606 IL Part B Supplier - Clinic/Group Practice 8628001203 Receives reassigned benefits from 8 practitioners
Practice locations: Libertyville, IL; Park City, IL; Vernon Hills, IL

National Provider Directory

National Provider Directory

Locations

270 Center Dr
Ste 130
Vernon Hills, IL 60061
Phone (847) 680-7100

Practitioners & affiliated clinicians

Practitioners 9

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": "1163376000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1902977937",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "351 S. GREENLEAF",
            "address_2": "SUITE E",
            "city": "PARK CITY",
            "state": "IL",
            "postal_code": "60085",
            "telephone_number": "847-680-7100",
            "fax_number": "847-406-3345"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "351 S. GREENLEAF",
            "address_2": "SUITE E",
            "city": "PARK CITY",
            "state": "IL",
            "postal_code": "60085",
            "telephone_number": "847-680-7100",
            "fax_number": "847-406-3345"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE SHORE DERMATOLOGY, LTD.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-13",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "GANDHI",
        "authorized_official_first_name": "KAVITHA",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "847-680-7100",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "IL",
            "license": "336067198",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Park City, 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.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.