Provider Demographics
NPI:1063442895
Name:LAKESIDE MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-447-8081
Mailing Address - Street 1:PO BOX 999
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0999
Mailing Address - Country:US
Mailing Address - Phone:434-447-8081
Mailing Address - Fax:434-447-8202
Practice Address - Street 1:200 E FERRELL ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-2104
Practice Address - Country:US
Practice Address - Phone:434-447-8081
Practice Address - Fax:434-447-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207R00000X, 207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD2229OtherRAILROAD MEDICARE
DD2229OtherRAILROAD MEDICARE