Provider Demographics
NPI:1528044468
Name:LAKESIDE ORTHOPAEDIC CENTER, LLC
Entity Type:Organization
Organization Name:LAKESIDE ORTHOPAEDIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODBURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-433-5633
Mailing Address - Street 1:50 E HOSPITAL ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3149
Mailing Address - Country:US
Mailing Address - Phone:803-433-5633
Mailing Address - Fax:803-433-5636
Practice Address - Street 1:50 E HOSPITAL ST
Practice Address - Street 2:SUITE 6
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3149
Practice Address - Country:US
Practice Address - Phone:803-433-5633
Practice Address - Fax:803-433-5636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27593207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC275936Medicaid
SCGP4233Medicaid
SC8310Medicare ID - Type UnspecifiedGROUP #
SC6447220001Medicare NSC
SCI37754Medicare UPIN
SCAA10258310Medicare ID - Type UnspecifiedPROVIDER ID