Provider Demographics
NPI:1043265739
Name:LAKESIDE SURGERY LTD
Entity Type:Organization
Organization Name:LAKESIDE SURGERY LTD
Other - Org Name:LAKESIDE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-206-2375
Mailing Address - Street 1:1825 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803
Mailing Address - Country:US
Mailing Address - Phone:407-206-2375
Mailing Address - Fax:407-206-2377
Practice Address - Street 1:1825 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803
Practice Address - Country:US
Practice Address - Phone:407-206-2375
Practice Address - Fax:407-206-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL288415OtherWELLCARE
FL97107OtherBCBS
FLK4027Medicare PIN