Provider Demographics
NPI:1073142147
Name:LAKESIDE MED, LLC
Entity Type:Organization
Organization Name:LAKESIDE MED, LLC
Other - Org Name:MASON-DIXON MOBILE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRIMARY MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:240-397-6723
Mailing Address - Street 1:723 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-5232
Mailing Address - Country:US
Mailing Address - Phone:240-397-6723
Mailing Address - Fax:833-992-0865
Practice Address - Street 1:723 N MARKET ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-5232
Practice Address - Country:US
Practice Address - Phone:240-397-6723
Practice Address - Fax:833-992-0865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-02
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty