Provider Demographics
NPI:1780746552
Name:LAKESIDE EAR, NOSE, & THROAT PHYSICIANS, PC
Entity type:Organization
Organization Name:LAKESIDE EAR, NOSE, & THROAT PHYSICIANS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:V
Authorized Official - Last Name:HUERTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-758-5600
Mailing Address - Street 1:17030 LAKESIDE HILLS PLZ
Mailing Address - Street 2:STE. 204
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2396
Mailing Address - Country:US
Mailing Address - Phone:402-758-5600
Mailing Address - Fax:402-758-5169
Practice Address - Street 1:17030 LAKESIDE HILLS PLZ
Practice Address - Street 2:STE. 204
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2396
Practice Address - Country:US
Practice Address - Phone:402-758-5600
Practice Address - Fax:402-758-5169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0201904Medicaid
NE=========00Medicaid
NE=========00Medicaid
NE099029Medicare PIN