Basic Information
| Provider Information | |||||||||
| NPI: | 1811295108 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESIDE WOMEN'S CENTER OF OKLAHOMA CITY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKESIDE PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8387 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049158300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059361577 | ||||||||
| FaxNumber: | 8663544053 | ||||||||
| Practice Location | |||||||||
| Address1: | 11200 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731205045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059361500 | ||||||||
| FaxNumber: | 4054180524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2011 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | MCCALLISTER | ||||||||
| AuthorizedOfficialFirstName: | DARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4059361554 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKESIDE WOMEN'S CENTER OF OKLAHOMA CITY, LLC | ||||||||
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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 | 000370199001 | 01 | OK | BCBS | OTHER | 100745350C | 05 | OK | MEDICAID |