MEDICARE: LAKESIDE PHYSICIANS MANAGEMENT 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1043402308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE PHYSICIANS MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	1512 NORTH BRAZOS
Second Line	:
City	:	WHITNEY
State	:	TX
Zip	:	76692
Country	:	US
Telephone Number	:	254-694-6871
Fax Number	:	254-694-6876

Provider Business Practice Location Address
First Line	:	1512 NORTH BRAZOS
Second Line	:
City	:	WHITNEY
State	:	TX
Zip	:	76692
Country	:	US
Telephone Number	:	254-694-6871
Fax Number	:	254-694-6876

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	MRS. DIANNA L ANDERSON
Credential	:
Telephone Number	:	254-694-6871

Provider Enumeration Date	:	08/10/2007
Last Update Date	:	09/30/2010

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