Healthcare Provider Details

I. General information

NPI: 1407992241
Provider Name (Legal Business Name): LAKESIDE ENDOSCOPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17001 LAKESIDE HILLS PLZ SUITE 201
OMAHA NE
68130
US

IV. Provider business mailing address

8901 INDIAN HILLS DR SUITE 200
OMAHA NE
68114
US

V. Phone/Fax

Practice location:
  • Phone: 402-614-2300
  • Fax: 402-505-4738
Mailing address:
  • Phone: 402-505-4713
  • Fax: 402-505-4738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberASC054
License Number StateNE

VIII. Authorized Official

Name: KIMBERLY S HARMON
Title or Position: MD
Credential: MD
Phone: 402-397-7057