Provider Demographics
NPI:1477872125
Name:LAKESIDE NEUROLOGY AND RADIOLOGY
Entity Type:Organization
Organization Name:LAKESIDE NEUROLOGY AND RADIOLOGY
Other - Org Name:LAKESIDE NEUROLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-416-1767
Mailing Address - Street 1:2516 WAUKEGAN RD
Mailing Address - Street 2:STE 386
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-1774
Mailing Address - Country:US
Mailing Address - Phone:800-416-1767
Mailing Address - Fax:888-317-4206
Practice Address - Street 1:12673 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5958
Practice Address - Country:US
Practice Address - Phone:800-416-1767
Practice Address - Fax:888-317-4206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty