Provider Demographics
NPI:1083048730
Name:LAKESIDE NEUROCARE
Entity Type:Organization
Organization Name:LAKESIDE NEUROCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:920-223-5582
Mailing Address - Street 1:2700 W 9TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7865
Mailing Address - Country:US
Mailing Address - Phone:920-223-5580
Mailing Address - Fax:920-223-3580
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7668
Practice Address - Country:US
Practice Address - Phone:920-223-5580
Practice Address - Fax:920-223-3580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32820600Medicaid
WI32820600Medicaid