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General NPI Number Information
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NPI Number | 1487709713
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Entity Type | Organization
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Legal Business Name | LAKESIDE SURGICAL ASSOCIATES, PA
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 07/06/2010
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Provider Practice Location Address
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Address Line | 150 FAIRVIEW RD SUITE 300
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City | MOORESVILLE
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State | NC
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Zip | 28117-9504
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Country | US
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Telephone | 704-664-6677
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Fax | 704-663-1009
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Provider Business Mailing Address
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Address Line | 150 FAIRVIEW RD SUITE 300
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City | MOORESVILLE
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State | NC
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Zip | 28117-9504
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Country | US
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Telephone | 704-664-6677
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Fax | 704-663-1009
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GREGORY B HALL
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Credential | M. D., F.A.C.S
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Telephone | 704-664-6677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 9600335
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License Number State | NC
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