MEDICARE: LAKESIDE NEUROLOGY 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	174400000X	Specialist	28212	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1659357929	OTHER	AZ	GROUP NPI NUMBER

General Provider Information

NPI Number	:	1609055276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE NEUROLOGY LLC

Provider Business Mailing Address
First Line	:	PO BOX 1440
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86405-1440
Country	:	US
Telephone Number	:	928-680-8282
Fax Number	:	928-680-8288

Provider Business Practice Location Address
First Line	:	2180 MCCULLOCH BLVD N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6879
Country	:	US
Telephone Number	:	928-680-8282
Fax Number	:	928-680-8288

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TIN T WIN
Credential	:	M.D.
Telephone Number	:	928-680-8282

Provider Enumeration Date	:	10/30/2007
Last Update Date	:	10/30/2007

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Directions to “LAKESIDE NEUROLOGY LLC ” Practice Location

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