Provider Demographics
NPI:1205919917
Name:LAKESIDE FAMILY PRACTICE PLLC
Entity type:Organization
Organization Name:LAKESIDE FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-594-2400
Mailing Address - Street 1:933 CHEAT RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-5631
Mailing Address - Country:US
Mailing Address - Phone:304-594-2400
Mailing Address - Fax:304-594-2256
Practice Address - Street 1:933 CHEAT RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-5631
Practice Address - Country:US
Practice Address - Phone:304-594-2400
Practice Address - Fax:304-594-2256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001709238OtherBLUE SHIELD GROUP PROVIDE
WV3810002243Medicaid
WV3810002243Medicaid