Healthcare Provider Details

I. General information

NPI: 1972721025
Provider Name (Legal Business Name): LAKEVIEW MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 WATERBURY FALLS DR STE 202
O FALLON MO
63368-2215
US

IV. Provider business mailing address

1630 MARKET CENTER BLVD STE 201
O FALLON MO
63368-8407
US

V. Phone/Fax

Practice location:
  • Phone: 636-278-1670
  • Fax:
Mailing address:
  • Phone: 636-397-4012
  • Fax: 636-278-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number108025
License Number StateMO

VIII. Authorized Official

Name: THOMAS F WRIGHT
Title or Position: PRESIDENT
Credential:
Phone: 636-397-4012