Provider Demographics
NPI:1386840502
Name:LAKESIDE INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:LAKESIDE INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-778-5287
Mailing Address - Street 1:21519 HARPER AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2220
Mailing Address - Country:US
Mailing Address - Phone:586-447-3017
Mailing Address - Fax:
Practice Address - Street 1:21519 HARPER AVE STE 109
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2209
Practice Address - Country:US
Practice Address - Phone:586-945-5012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058249261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5199450Medicaid
G16772Medicare UPIN
MI0M17390Medicare PIN