NPIMap

Organization Active NPI

Upmc Community Medicine

Doing business as Lakeside Family Medicine Conneaut Lake

  • Non-Pharmacy Dispensing Site
  • Conneaut Lake, PA
National Provider Identifier
1013316553
Registry record updated Aug 21, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Non-Pharmacy Dispensing SiteTaxonomy code 332900000X
License
OS012755 Issued in PA
Legal business name
UPMC COMMUNITY MEDICINE
Doing business as
Lakeside Family Medicine Conneaut Lake
Practice address
11065 State Highway 18
Suite 1
Conneaut Lake, PA 16316-3569
Phone
(814) 382-6550
NPI assigned
Aug 21, 2014
Last updated
Aug 21, 2014By the provider in NPPES
Organization subpart
Yes
Parent organization
MEDVANTX, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 21, 2014

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

Authorized official

Name
Kenny Heine
Title
VP of Operations
Phone
(858) 964-1506

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Non-Pharmacy Dispensing Site 332900000X OS012755 PA Primary

Addresses

Primary practice location

11065 State Highway 18
Suite 1
Conneaut Lake, PA 16316-3569

Mailing address

5626 Oberlin Dr
Suite 110
San Diego, CA 92121-1705

Other names 1

  • Lakeside Family Medicine Conneaut Lake Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Univ Fam Prac MCM200 organizations share this tax ID, including this one
Part of
Medvantx Inc

Organizations with this tax ID in the same state 13

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1408579200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1408579200000",
    "number": "1013316553",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5626 OBERLIN DR",
            "address_2": "SUITE 110",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921211705"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11065 STATE HIGHWAY 18",
            "address_2": "SUITE 1",
            "city": "CONNEAUT LAKE",
            "state": "PA",
            "postal_code": "163163569",
            "telephone_number": "814-382-6550"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UPMC COMMUNITY MEDICINE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MEDVANTX, INC",
        "enumeration_date": "2014-08-21",
        "last_updated": "2014-08-21",
        "status": "A",
        "authorized_official_last_name": "HEINE",
        "authorized_official_first_name": "KENNY",
        "authorized_official_title_or_position": "VP OF OPERATIONS",
        "authorized_official_telephone_number": "858-964-1506"
    },
    "taxonomies": [
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "PA",
            "license": "OS012755",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeside Family Medicine Conneaut Lake",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Conneaut Lake, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 21, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.