NPIMap

Organization Active NPI

Lakeside Pediatric & Adolescent Medicine, PLLC

  • Pediatric Adolescent Medicine Physician
  • Coeur D'Alene, ID
National Provider Identifier
1003975087
Registry record updated Jul 12, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X
Legal business name
LAKESIDE PEDIATRIC & ADOLESCENT MEDICINE, PLLC
Practice address
980 W Ironwood Dr
Ste 302
Coeur D'Alene, ID 83814-2601
Phone
(208) 292-5437
Fax
(208) 292-5441
NPI assigned
Dec 6, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 12, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Diana R Vanhook
Title
Office Manager
Phone
(208) 292-5437

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Adolescent Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2080A0000X Primary

Addresses

Primary practice location

980 W Ironwood Dr
Ste 302
Coeur D'Alene, ID 83814-2601

Mailing address

980 W Ironwood Dr
Ste 302
Coeur D'Alene, ID 83814-2601
Phone (208) 292-5437

Other identifiers 2

IdentifierTypeStateIssuer
806408200MedicaidID
4010138351OtherIDREGENCE BLUE SHIELD GROUP

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
13D1004948Lakeside Pediatric & Adolescent Medicine PLLC980 W Ironwood Dr Ste #302, Coeur D'Alene, ID 83814Certificate of waiverDec 14, 2026

National Provider Directory

National Provider Directory

Locations

980 W Ironwood Dr
Ste 302
Coeur D Alene, ID 83814
Phone (208) 292-5437

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165363200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1342051200000",
    "number": "1003975087",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "980 W IRONWOOD DR",
            "address_2": "STE 302",
            "city": "COEUR D'ALENE",
            "state": "ID",
            "postal_code": "838142601",
            "telephone_number": "208-292-5437",
            "fax_number": "208-292-5441"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "980 W IRONWOOD DR",
            "address_2": "STE 302",
            "city": "COEUR D'ALENE",
            "state": "ID",
            "postal_code": "838142601",
            "telephone_number": "208-292-5437",
            "fax_number": "208-292-5441"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESIDE PEDIATRIC & ADOLESCENT MEDICINE, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-06",
        "last_updated": "2012-07-12",
        "status": "A",
        "authorized_official_last_name": "VANHOOK",
        "authorized_official_first_name": "DIANA",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "208-292-5437"
    },
    "taxonomies": [
        {
            "code": "2080A0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806408200",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD GROUP",
            "identifier": "4010138351",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Coeur D'Alene, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 12, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.