Provider Demographics
NPI:1407992241
Name:LAKESIDE ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:LAKESIDE ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-504-3880
Mailing Address - Street 1:8901 INDIAN HILLS DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114
Mailing Address - Country:US
Mailing Address - Phone:402-505-4713
Mailing Address - Fax:402-505-4738
Practice Address - Street 1:17001 LAKESIDE HILLS PLZ
Practice Address - Street 2:SUITE 201
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130
Practice Address - Country:US
Practice Address - Phone:402-614-2300
Practice Address - Fax:402-505-4738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
NEASC054261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENA1108Medicare PIN