Provider Demographics
NPI:1104907807
Name:LAKESIDE WOMEN'S SPECIALTY CENTER, APMC
Entity type:Organization
Organization Name:LAKESIDE WOMEN'S SPECIALTY CENTER, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-885-8563
Mailing Address - Street 1:4315 HOUMA BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2940
Mailing Address - Country:US
Mailing Address - Phone:504-885-8563
Mailing Address - Fax:504-455-1072
Practice Address - Street 1:4315 HOUMA BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2940
Practice Address - Country:US
Practice Address - Phone:504-885-8563
Practice Address - Fax:504-455-1072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1942561Medicaid
LA1942561Medicaid