Provider Demographics
NPI:1699933838
Name:LAKESIDE OBSTETRICS & GYNECOLOGY LLC
Entity type:Organization
Organization Name:LAKESIDE OBSTETRICS & GYNECOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-302-1114
Mailing Address - Street 1:980 PARKSIDE VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3098
Mailing Address - Country:US
Mailing Address - Phone:573-302-1114
Mailing Address - Fax:573-302-0077
Practice Address - Street 1:980 PARKSIDE VILLAGE LN
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3098
Practice Address - Country:US
Practice Address - Phone:573-302-1114
Practice Address - Fax:573-302-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008006546207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty