Provider Demographics
NPI:1366650707
Name:LAKESHORE PEDIATRIC CENTER, P.A.
Entity Type:Organization
Organization Name:LAKESHORE PEDIATRIC CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WISSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NADRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-489-8401
Mailing Address - Street 1:275 N HWY 16
Mailing Address - Street 2:SUITE: 103 LAKESHORE PEDIATRIC CENTER.
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037
Mailing Address - Country:US
Mailing Address - Phone:704-489-8401
Mailing Address - Fax:704-489-8404
Practice Address - Street 1:275 N HWY 16
Practice Address - Street 2:SUITE: 103 LAKESHORE PEDIATRIC CENTER.
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037
Practice Address - Country:US
Practice Address - Phone:704-489-8401
Practice Address - Fax:704-489-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000-00103208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950140Medicaid
NC5950140Medicaid