1104880426 NPI number — LAKESIDE PEDIATRICS, PLLC

Table of content: (NPI 1104880426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104880426 NPI number — LAKESIDE PEDIATRICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE PEDIATRICS, 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:
HAGAN, RINEHART & CONNOLLY PEDIATRICS
Provider Other Organization Name Type Code:
4
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:
1104880426
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 LAKESIDE AVE
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401-4939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-860-1928
Provider Business Mailing Address Fax Number:
802-860-0192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 LAKESIDE AVE
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401-4939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-860-1928
Provider Business Practice Location Address Fax Number:
802-860-0192
Provider Enumeration Date:
04/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERGERON
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
802-860-1928

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0420006081 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33869 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 58026HAGA . This is a "BCBS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1007673 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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