Provider Demographics
NPI:1972721025
Name:LAKEVIEW MEDICAL GROUP INC
Entity type:Organization
Organization Name:LAKEVIEW MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-397-4012
Mailing Address - Street 1:1630 MARKET CENTER BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8407
Mailing Address - Country:US
Mailing Address - Phone:636-397-4012
Mailing Address - Fax:636-278-1670
Practice Address - Street 1:830 WATERBURY FALLS DR
Practice Address - Street 2:STE 202
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-2215
Practice Address - Country:US
Practice Address - Phone:636-278-1670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108025207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013627OtherMEDICARE GROUP PTAN
MO000013627OtherMEDICARE GROUP PTAN
MOF61506Medicare UPIN