Provider Demographics
NPI:1043402308
Name:LAKESIDE PHYSICIANS MANAGEMENT LLC
Entity Type:Organization
Organization Name:LAKESIDE PHYSICIANS MANAGEMENT LLC
Other - Org Name:LAKESIDE HEALTHCARE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-694-6871
Mailing Address - Street 1:1512 NORTH BRAZOS
Mailing Address - Street 2:
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692
Mailing Address - Country:US
Mailing Address - Phone:254-694-6871
Mailing Address - Fax:254-694-6876
Practice Address - Street 1:1512 NORTH BRAZOS
Practice Address - Street 2:
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692
Practice Address - Country:US
Practice Address - Phone:254-694-6871
Practice Address - Fax:254-694-6876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A4603Medicare PIN