Provider Demographics
NPI:1528176179
Name:LAKESIDE FAMILY PRACTICE PC
Entity type:Organization
Organization Name:LAKESIDE FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHENG
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-828-5020
Mailing Address - Street 1:416 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1737
Mailing Address - Country:US
Mailing Address - Phone:508-828-5020
Mailing Address - Fax:508-386-1323
Practice Address - Street 1:416 BROADWAY
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1737
Practice Address - Country:US
Practice Address - Phone:508-828-5020
Practice Address - Fax:508-386-1323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
M21188Medicare ID - Type Unspecified