Provider Demographics
NPI:1356481493
Name:LAKESIDE ENT, P.C.
Entity Type:Organization
Organization Name:LAKESIDE ENT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANDERMEER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-393-2190
Mailing Address - Street 1:577 MICHIGAN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4911
Mailing Address - Country:US
Mailing Address - Phone:616-393-2190
Mailing Address - Fax:616-393-0147
Practice Address - Street 1:577 MICHIGAN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4911
Practice Address - Country:US
Practice Address - Phone:616-393-2190
Practice Address - Fax:616-393-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty