Provider Demographics
NPI:1619396728
Name:MSO CLINICS, INC.
Entity Type:Organization
Organization Name:MSO CLINICS, INC.
Other - Org Name:LAKESIDE FAMILY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:812-268-4311
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-0230
Mailing Address - Country:US
Mailing Address - Phone:812-268-3318
Mailing Address - Fax:812-268-4017
Practice Address - Street 1:2186 N HOSPITAL BLVD #2
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7523
Practice Address - Country:US
Practice Address - Phone:812-268-3318
Practice Address - Fax:812-268-4017
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SULLIVAN COUNTY COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-16
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201246990BMedicaid
ININ2042OtherMEDICARE PART B