Provider Demographics
NPI:1770696171
Name:LAKESIDE UROLOGY PC
Entity type:Organization
Organization Name:LAKESIDE UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-982-4272
Mailing Address - Street 1:815 SAINT JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2529
Mailing Address - Country:US
Mailing Address - Phone:269-982-4272
Mailing Address - Fax:269-983-5920
Practice Address - Street 1:815 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2529
Practice Address - Country:US
Practice Address - Phone:269-982-4272
Practice Address - Fax:269-983-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A11030OtherBCBS MI
CG4706Medicare PIN
IN207050Medicare PIN
MI0M95670Medicare PIN