Provider Demographics
NPI:1356537708
Name:LAKESIDE NEUROLOGY & RADIOLOGY OF NEW JERSEY PC
Entity type:Organization
Organization Name:LAKESIDE NEUROLOGY & RADIOLOGY OF NEW JERSEY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:G
Authorized Official - Last Name:WINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-510-0530
Mailing Address - Street 1:1 GATEWAY CTR
Mailing Address - Street 2:#2600
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-5310
Mailing Address - Country:US
Mailing Address - Phone:847-510-0530
Mailing Address - Fax:888-317-4206
Practice Address - Street 1:1 GATEWAY CTR
Practice Address - Street 2:#2600
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-5310
Practice Address - Country:US
Practice Address - Phone:847-510-0530
Practice Address - Fax:888-317-4206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07746800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty