Provider Demographics
NPI:1326317520
Name:LAKESIDE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:LAKESIDE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:B
Authorized Official - Last Name:BAGHERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-886-5437
Mailing Address - Street 1:11565 MOUNTAIN LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1333
Mailing Address - Country:US
Mailing Address - Phone:770-886-5437
Mailing Address - Fax:770-886-9717
Practice Address - Street 1:204 CANTON RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2304
Practice Address - Country:US
Practice Address - Phone:770-886-5437
Practice Address - Fax:770-886-9717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040865208000000X
GA050209208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty