Provider Demographics
NPI:1386769180
Name:LAKESIDE MEDICAL GROUP, PC
Entity type:Organization
Organization Name:LAKESIDE MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-628-0220
Mailing Address - Street 1:72 S WASHINGTON ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-4973
Mailing Address - Country:US
Mailing Address - Phone:248-628-0220
Mailing Address - Fax:248-628-0226
Practice Address - Street 1:72 S WASHINGTON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-4973
Practice Address - Country:US
Practice Address - Phone:248-628-0220
Practice Address - Fax:248-628-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISH007361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0856300954OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI291878311Medicaid
MI207Q00000XOtherTAXONOMY
MI207Q00000XOtherTAXONOMY
MI0M60200001Medicare PIN
MI0856300954OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0M60200Medicare PIN