Provider Demographics
NPI:1831468800
Name:LAKESIDE SURGERY PA
Entity Type:Organization
Organization Name:LAKESIDE SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:R
Authorized Official - Last Name:PHILLIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-722-3290
Mailing Address - Street 1:4450 TUBBS RD
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6308
Mailing Address - Country:US
Mailing Address - Phone:972-722-3290
Mailing Address - Fax:972-722-3815
Practice Address - Street 1:4450 TUBBS RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6308
Practice Address - Country:US
Practice Address - Phone:972-772-3290
Practice Address - Fax:972-722-3815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6483208600000X
TXJ2983208600000X
TXP6593208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1326097676OtherNPI #
TX1952393415OtherNPI #
TXJ2983OtherTX LICENSE
TXK6483OtherTX LICENSE
TXP6593OtherSTATE LICENSE
TX=========OtherTIN#