Provider Demographics
NPI:1073549291
Name:LIDE, LANNEAU D JR (MD)
Entity Type:Individual
Prefix:
First Name:LANNEAU
Middle Name:D
Last Name:LIDE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1018
Mailing Address - Country:US
Mailing Address - Phone:803-255-2655
Mailing Address - Fax:803-255-2484
Practice Address - Street 1:2001 LAUREL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1018
Practice Address - Country:US
Practice Address - Phone:803-254-3278
Practice Address - Fax:803-929-3256
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10233207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC102338Medicaid
SCB91787Medicare UPIN