Provider Demographics
NPI:1801238787
Name:LAKESHORE PEDIATRICS PC
Entity type:Organization
Organization Name:LAKESHORE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AGUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-386-4151
Mailing Address - Street 1:1120 S JACKSON HWY STE 304
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660-5773
Mailing Address - Country:US
Mailing Address - Phone:256-386-4151
Mailing Address - Fax:
Practice Address - Street 1:12521 AL HIGHWAY 157 STE B
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650-1937
Practice Address - Country:US
Practice Address - Phone:256-974-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17108261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1588002455Medicaid