Provider Demographics
NPI:1336492495
Name:LAKESIDE HEALTH CLINIC, P.C.
Entity Type:Organization
Organization Name:LAKESIDE HEALTH CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PA-C
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:731-924-2000
Mailing Address - Street 1:PO BOX 1269
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-1269
Mailing Address - Country:US
Mailing Address - Phone:731-924-2000
Mailing Address - Fax:731-653-0053
Practice Address - Street 1:813 E WOOD ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4223
Practice Address - Country:US
Practice Address - Phone:731-924-2000
Practice Address - Fax:731-653-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530820Medicaid
TN103G701958Medicare PIN
TNQ67041Medicare UPIN