Provider Demographics
NPI:1871564609
Name:LAKESIDE FAMILY HEALTH CENTER PC
Entity type:Organization
Organization Name:LAKESIDE FAMILY HEALTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-537-4379
Mailing Address - Street 1:5658 HIGHWAY 260 STE 24
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5189
Mailing Address - Country:US
Mailing Address - Phone:928-537-4379
Mailing Address - Fax:
Practice Address - Street 1:5658 HIGHWAY 260
Practice Address - Street 2:SUITE 24
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5189
Practice Address - Country:US
Practice Address - Phone:928-537-4379
Practice Address - Fax:928-537-4653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
104888Medicare ID - Type Unspecified