Provider Demographics
NPI:1124246160
Name:THE LAKE'S LIVER AND DIGESTIVE HEALTH CENTER INC
Entity type:Organization
Organization Name:THE LAKE'S LIVER AND DIGESTIVE HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:BYRNE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-302-7138
Mailing Address - Street 1:1029 NICHOLS RD STE 201
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3008
Mailing Address - Country:US
Mailing Address - Phone:573-302-7138
Mailing Address - Fax:573-302-4686
Practice Address - Street 1:1029 NICHOLS RD STE 201
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3008
Practice Address - Country:US
Practice Address - Phone:573-302-7138
Practice Address - Fax:573-302-4686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO107693207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507523900Medicaid
MODG1541OtherRR MEDICARE
MO16408OtherANTHEM BCBS PROVIDER ID
MO277180OtherHEALTHLINK PROIVDER ID
MOE71349Medicare UPIN
MO277180OtherHEALTHLINK PROIVDER ID