Provider Demographics
NPI:1134467129
Name:OBGYN SPECIALISTS OF LAKESIDE LLC
Entity Type:Organization
Organization Name:OBGYN SPECIALISTS OF LAKESIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURIGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-275-7509
Mailing Address - Street 1:2979 PGA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-2911
Mailing Address - Country:US
Mailing Address - Phone:561-275-7604
Mailing Address - Fax:561-802-5385
Practice Address - Street 1:39200 HOOKER HWY
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-5368
Practice Address - Country:US
Practice Address - Phone:561-996-6571
Practice Address - Fax:561-992-9722
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OBGYN SPECIALISTS OF THE PALM BEACHES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-25
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35335207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008257000Medicaid
FLHE580AMedicare PIN