Provider Demographics
NPI:1003823717
Name:LAKE SHORE PHYSICIAN PA
Entity Type:Organization
Organization Name:LAKE SHORE PHYSICIAN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:FOLKEMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-437-3200
Mailing Address - Street 1:4231 POSTAL COURT
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122
Mailing Address - Country:US
Mailing Address - Phone:410-432-3200
Mailing Address - Fax:410-437-9402
Practice Address - Street 1:4231 POSTAL COURT
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122
Practice Address - Country:US
Practice Address - Phone:410-432-3200
Practice Address - Fax:410-437-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD14751207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
185PMedicare ID - Type Unspecified
B69462Medicare UPIN