Provider Demographics
NPI:1194907394
Name:LAKESHORE PEDIATRICS OF RUSSELLVILLE
Entity type:Organization
Organization Name:LAKESHORE PEDIATRICS OF RUSSELLVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AGUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-386-4151
Mailing Address - Street 1:1120 S JACKSON HWY
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660-5777
Mailing Address - Country:US
Mailing Address - Phone:256-386-4151
Mailing Address - Fax:256-383-7293
Practice Address - Street 1:603 GANDY ST NE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1911
Practice Address - Country:US
Practice Address - Phone:256-331-5055
Practice Address - Fax:256-383-7293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2006323208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty