Provider Demographics
NPI:1063854420
Name:LAKESIDE INTERNAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:LAKESIDE INTERNAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:KU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-895-7600
Mailing Address - Street 1:10450 E RIGGS RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-7757
Mailing Address - Country:US
Mailing Address - Phone:480-895-7600
Mailing Address - Fax:480-895-7601
Practice Address - Street 1:10450 E RIGGS RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-7757
Practice Address - Country:US
Practice Address - Phone:480-895-7600
Practice Address - Fax:480-895-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty