Provider Demographics
NPI:1518293323
Name:LAKEVIEW INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:LAKEVIEW INTERNAL MEDICINE, LLC
Other - Org Name:LAKEVIEW INTERNAL MEDICINE AND SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GROUP VP/AO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TEDRICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-3375
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-373-7406
Mailing Address - Fax:866-346-1426
Practice Address - Street 1:444 W BOURNE CIR STE 101
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-3657
Practice Address - Country:US
Practice Address - Phone:801-294-9333
Practice Address - Fax:801-294-7558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1518293323Medicaid
UT000068310Medicare PIN