1073142147 NPI number — LAKESIDE MED, LLC

Table of content: (NPI 1073142147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073142147 NPI number — LAKESIDE MED, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE MED, LLC
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:
MASON-DIXON MOBILE MEDICINE
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:
1073142147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
723 N MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21701-5232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-397-6723
Provider Business Mailing Address Fax Number:
833-992-0865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
723 N MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21701-5232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-397-6723
Provider Business Practice Location Address Fax Number:
833-992-0865
Provider Enumeration Date:
04/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
PRIMARY MEMBER
Authorized Official Telephone Number:
240-397-6723

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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