Provider Demographics
NPI:1104880426
Name:LAKESIDE PEDIATRICS, PLLC
Entity type:Organization
Organization Name:LAKESIDE PEDIATRICS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-860-1928
Mailing Address - Street 1:128 LAKESIDE AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4939
Mailing Address - Country:US
Mailing Address - Phone:802-860-1928
Mailing Address - Fax:802-860-0192
Practice Address - Street 1:128 LAKESIDE AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4939
Practice Address - Country:US
Practice Address - Phone:802-860-1928
Practice Address - Fax:802-860-0192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420006081208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT33869OtherMVP
VT58026HAGAOtherBCBS
VT1007673Medicaid