Provider Demographics
NPI:1477897023
Name:LAKESIDE ANESTHESIOLOGY, S.C
Entity Type:Organization
Organization Name:LAKESIDE ANESTHESIOLOGY, S.C
Other - Org Name:1BODY4LIFE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOOTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-209-2525
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:761 HIGHGROVE PL
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2520
Practice Address - Country:US
Practice Address - Phone:815-209-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESIDE ANESTHESIOLOGY, S.C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site