1689611550 NPI number — LAKESHORE ANESTHESIA GROUP, PLLC

Table of content: (NPI 1689611550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689611550 NPI number — LAKESHORE ANESTHESIA GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE ANESTHESIA GROUP, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689611550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 181780
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75218-8780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-236-5643
Provider Business Mailing Address Fax Number:
214-321-9160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9440 POPPY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75218-3652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-324-6100
Provider Business Practice Location Address Fax Number:
214-324-6141
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLSON
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-236-5643

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00C09V . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 185036401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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