Provider Demographics
NPI:1225333073
Name:LAKESHORE FAMILY MEDICINE ASSOCIATES, APMC
Entity Type:Organization
Organization Name:LAKESHORE FAMILY MEDICINE ASSOCIATES, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ST CLAIR
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:SR
Authorized Official - Credentials:M D
Authorized Official - Phone:318-343-6487
Mailing Address - Street 1:PO BOX 13430
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71213-3430
Mailing Address - Country:US
Mailing Address - Phone:318-343-6487
Mailing Address - Fax:318-343-7884
Practice Address - Street 1:516 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-4252
Practice Address - Country:US
Practice Address - Phone:318-343-6487
Practice Address - Fax:318-343-7884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022964207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1685895Medicaid
LA1685895Medicaid
G64048Medicare UPIN