Provider Demographics
NPI:1477566727
Name:LAKESIDE PAIN CENTER, P.C.
Entity Type:Organization
Organization Name:LAKESIDE PAIN CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-475-9220
Mailing Address - Street 1:6010 LAKESIDE COMMONS DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210
Mailing Address - Country:US
Mailing Address - Phone:478-475-9220
Mailing Address - Fax:478-475-9201
Practice Address - Street 1:6010 LAKESIDE COMMONS DR
Practice Address - Street 2:SUITE A
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5779
Practice Address - Country:US
Practice Address - Phone:478-475-9220
Practice Address - Fax:478-475-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042215208100000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty