MEDICARE: LAKESIDE FAMILY PRACTICE PLLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001709238	OTHER	WV	BLUE SHIELD GROUP PROVIDE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205919917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE FAMILY PRACTICE PLLC

Provider Business Mailing Address
First Line	:	933 CHEAT RD
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26508-5631
Country	:	US
Telephone Number	:	304-594-2400
Fax Number	:	304-594-2256

Provider Business Practice Location Address
First Line	:	933 CHEAT RD
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26508-5631
Country	:	US
Telephone Number	:	304-594-2400
Fax Number	:	304-594-2256

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRIAN W HAWTHORNE
Credential	:	M.D.
Telephone Number	:	304-594-2400

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	05/09/2011

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Directions to “LAKESIDE FAMILY PRACTICE PLLC ” Practice Location

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