MEDICARE: LAKESIDE ORTHOPAEDIC CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	27593	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528044468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE ORTHOPAEDIC CENTER, LLC

Provider Business Mailing Address
First Line	:	50 E HOSPITAL ST
Second Line	:	SUITE 6
City	:	MANNING
State	:	SC
Zip	:	29102-3149
Country	:	US
Telephone Number	:	803-433-5633
Fax Number	:	803-433-5636

Provider Business Practice Location Address
First Line	:	50 E HOSPITAL ST
Second Line	:	SUITE 6
City	:	MANNING
State	:	SC
Zip	:	29102-3149
Country	:	US
Telephone Number	:	803-433-5633
Fax Number	:	803-433-5636

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID WOODBURY
Credential	:	MD
Telephone Number	:	803-433-5633

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	07/27/2012

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