Provider Demographics
NPI:1003975087
Name:LAKESIDE PEDIATRIC & ADOLESCENT MEDICINE, PLLC
Entity Type:Organization
Organization Name:LAKESIDE PEDIATRIC & ADOLESCENT MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANHOOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-292-5437
Mailing Address - Street 1:980 W IRONWOOD DR
Mailing Address - Street 2:STE 302
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2601
Mailing Address - Country:US
Mailing Address - Phone:208-292-5437
Mailing Address - Fax:208-292-5441
Practice Address - Street 1:980 W IRONWOOD DR
Practice Address - Street 2:STE 302
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2601
Practice Address - Country:US
Practice Address - Phone:208-292-5437
Practice Address - Fax:208-292-5441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806408200Medicaid
ID4010138351OtherREGENCE BLUE SHIELD GROUP