Basic Information
| Provider Information | |||||||||
| NPI: | 1518146497 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE WOMENS SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 TULANE AVE | ||||||||
| Address2: | HC71 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049887535 | ||||||||
| FaxNumber: | 5049886288 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 S I 10 SERVICE RD W | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700011269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049886872 | ||||||||
| FaxNumber: | 5049886288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | LAGESSE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5049887535 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY HEALTHCARE SYSTEM LC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | DG8660 | 01 | LA | RAILROAD MEDICARE | OTHER | 06307864 | 05 | MS | MEDICAID |