Provider Demographics
NPI:1508058835
Name:LAKESIDE ORTHOPEDICS PC
Entity Type:Organization
Organization Name:LAKESIDE ORTHOPEDICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-758-5690
Mailing Address - Street 1:16909 LAKESIDE HILLS CT
Mailing Address - Street 2:SUITE 208
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-4664
Mailing Address - Country:US
Mailing Address - Phone:402-758-5690
Mailing Address - Fax:402-758-5699
Practice Address - Street 1:1413 SOUTH WASHINTON
Practice Address - Street 2:SUITE 200
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046
Practice Address - Country:US
Practice Address - Phone:402-758-5690
Practice Address - Fax:402-758-5699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025497200Medicaid
NE10025497200Medicaid
NE099864Medicare Oscar/Certification