Provider Demographics
NPI:1669538377
Name:LAKEWOOD ORTHOPAEDICS & SPORTS MEDICINE, PA
Entity type:Organization
Organization Name:LAKEWOOD ORTHOPAEDICS & SPORTS MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-341-5676
Mailing Address - Street 1:1130 BEACHVIEW ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-3700
Mailing Address - Country:US
Mailing Address - Phone:469-341-5676
Mailing Address - Fax:469-341-5677
Practice Address - Street 1:1130 BEACHVIEW
Practice Address - Street 2:SUITE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3697
Practice Address - Country:US
Practice Address - Phone:469-341-5676
Practice Address - Fax:469-341-5677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKEWOOD ORTHOPAEDICS & SPORTS MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-28
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX610541200OtherDOL
TX176468001Medicaid
00035ZOtherMEDICARE GROUP
0031MSOtherBCBS
TX5475440001Medicare NSC