Provider Demographics
NPI:1811295108
Name:LAKESIDE WOMEN'S CENTER OF OKLAHOMA CITY, LLC
Entity type:Organization
Organization Name:LAKESIDE WOMEN'S CENTER OF OKLAHOMA CITY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-936-1554
Mailing Address - Street 1:PO BOX 8387
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8300
Mailing Address - Country:US
Mailing Address - Phone:405-936-1577
Mailing Address - Fax:866-354-4053
Practice Address - Street 1:11200 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5045
Practice Address - Country:US
Practice Address - Phone:405-936-1500
Practice Address - Fax:405-418-0524
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESIDE WOMEN'S CENTER OF OKLAHOMA CITY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-10
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000370199001OtherBCBS
OK100745350CMedicaid
OK100745350CMedicaid