Provider Demographics
NPI:1609119585
Name:LAKESIDE MEDICAL IMAGING LLC
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-362-6909
Mailing Address - Street 1:PO BOX 674351
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4351
Mailing Address - Country:US
Mailing Address - Phone:847-458-1460
Mailing Address - Fax:847-458-1942
Practice Address - Street 1:1154 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-3482
Practice Address - Country:US
Practice Address - Phone:847-458-1460
Practice Address - Fax:847-458-1942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)