Healthcare Provider Details

I. General information

NPI: 1902137417
Provider Name (Legal Business Name): LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 EAST TYSON RD
QUARTZSITE AZ
85359
US

IV. Provider business mailing address

25 RIVIERA BLVD
LAKE HAVASU CITY AZ
86403-5694
US

V. Phone/Fax

Practice location:
  • Phone: 928-505-5555
  • Fax: 928-505-2877
Mailing address:
  • Phone: 928-505-5555
  • Fax: 928-505-2877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number23186
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number34564
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number26379
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0554
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number13802
License Number StateAZ

VIII. Authorized Official

Name: WILLIAM F BINDER
Title or Position: PARTNER
Credential: M.D.
Phone: 928-505-5555