Provider Demographics
NPI:1891808085
Name:LAKE PLEASANT INTERNAL MEDICINE PLC
Entity Type:Organization
Organization Name:LAKE PLEASANT INTERNAL MEDICINE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:CHUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-455-3317
Mailing Address - Street 1:9059 W LAKE PLEASANT PKWY
Mailing Address - Street 2:STE C-320
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-8336
Mailing Address - Country:US
Mailing Address - Phone:623-455-3317
Mailing Address - Fax:623-256-6551
Practice Address - Street 1:9059 W LAKE PLEASANT PKWY
Practice Address - Street 2:STE C-320
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8336
Practice Address - Country:US
Practice Address - Phone:623-455-3317
Practice Address - Fax:623-256-6551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31697207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ795974Medicaid
AZZ111358Medicare PIN