MEDICARE: LAKESIDE FAMILY HEALTH CENTER PC

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	363LW0102X	Women's Health Nurse Practitioner
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1871564609
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE FAMILY HEALTH CENTER PC

Provider Business Mailing Address
First Line	:	5658 HIGHWAY 260 STE 24
Second Line	:
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5189
Country	:	US
Telephone Number	:	928-537-4379
Fax Number	:

Provider Business Practice Location Address
First Line	:	5658 HIGHWAY 260
Second Line	:	SUITE 24
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5189
Country	:	US
Telephone Number	:	928-537-4379
Fax Number	:	928-537-4653

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLES ROBERTSON
Credential	:	MD
Telephone Number	:	928-537-4379

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	01/26/2015

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Directions to “LAKESIDE FAMILY HEALTH CENTER PC ” Practice Location

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