Provider Demographics
NPI:1467527648
Name:LAKESIDE HEALTHCARE SPECIALISTS PLLC
Entity Type:Organization
Organization Name:LAKESIDE HEALTHCARE SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DESKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-983-0500
Mailing Address - Street 1:3950 HOLLYWOOD RD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9159
Mailing Address - Country:US
Mailing Address - Phone:269-983-0500
Mailing Address - Fax:269-429-2240
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 270
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9159
Practice Address - Country:US
Practice Address - Phone:269-983-0500
Practice Address - Fax:269-429-2240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISD062237207R00000X
MIKA036485207R00000X
MIMS007105207R00000X
MIAP062392207R00000X
MISW015533207R00000X
MIDP065168207R00000X
MIVS046079207RA0000X
MISS036858207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A110280OtherBCBS
MICG8207OtherRAIL ROAD MEDICARE
MICG8207OtherRAIL ROAD MEDICARE