1851489520 NPI number — LAKESIDE SURGERY, P.A.

Table of content: (NPI 1851489520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851489520 NPI number — LAKESIDE SURGERY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE SURGERY, P.A.
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:
LAKESIDE SURGERY, P.A.
Provider Other Organization Name Type Code:
3
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:
1851489520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2850 SHORELINE TRL
Provider Second Line Business Mailing Address:
PMB 154
Provider Business Mailing Address City Name:
ROCKWALL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75032-5508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-772-3290
Provider Business Mailing Address Fax Number:
469-402-2585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3142 HORIZON RD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
ROCKWALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75032-7809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-722-3290
Provider Business Practice Location Address Fax Number:
469-402-2585
Provider Enumeration Date:
10/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAKOHON
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
SURGEON/OWNER
Authorized Official Telephone Number:
972-722-3290

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  K6483 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: J2983 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: P6593 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1326097676 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1952393415 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".