Provider Demographics
NPI:1346428331
Name:LAKESHORE CLINIC, P C
Entity Type:Organization
Organization Name:LAKESHORE CLINIC, P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERTRUDE
Authorized Official - Middle Name:E
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-687-5775
Mailing Address - Street 1:1026 S EUFAULA AVE
Mailing Address - Street 2:
Mailing Address - City:EUFAULA
Mailing Address - State:AL
Mailing Address - Zip Code:36027-2702
Mailing Address - Country:US
Mailing Address - Phone:334-687-5775
Mailing Address - Fax:334-687-5095
Practice Address - Street 1:1026 S EUFAULA AVE
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:AL
Practice Address - Zip Code:36027-2702
Practice Address - Country:US
Practice Address - Phone:334-687-5775
Practice Address - Fax:334-687-5095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16148207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty