Active NPI
Lakeside Family Medicine
- Family Medicine Physician
- Kingston, OK
National Provider Identifier
1295064178
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 19862
- Legal business name
- LAKESIDE FAMILY MEDICINE
- Practice address
- 21 N. Main Street
Kingston, OK 73439-1798 - Phone
- (580) 226-1010
- NPI assigned
- Dec 23, 2009
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Pamela E Ahearn, MD
- Title
- Owner/President
- Phone
- (580) 226-1010
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 19862 | OK | Primary |
Addresses
Primary practice location
21 N. Main Street
Kingston, OK 73439-1798
Mailing address
PO Box 1798
Kingston, OK 73439-1798
Phone (580) 226-1010
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| PENDING | Medicaid | OK |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in OK
Enrollment records 1
National Provider Directory
National Provider Directory- Tax ID family
- Lakeside Family Medicine
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
- Family Medicine Physician
- Kingston, OK
- NPI 1790188639
Practitioners & affiliated clinicians
Practitioners 5
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Internal Medicine Physician
- Durant, OK
- NPI 1275827305
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1261526400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1261526400000",
"number": "1295064178",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1798",
"city": "KINGSTON",
"state": "OK",
"postal_code": "734391798",
"telephone_number": "580-226-1010"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "21 N. MAIN STREET",
"city": "KINGSTON",
"state": "OK",
"postal_code": "734391798",
"telephone_number": "580-226-1010"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "LAKESIDE FAMILY MEDICINE",
"organizational_subpart": "NO",
"enumeration_date": "2009-12-23",
"last_updated": "2009-12-23",
"status": "A",
"authorized_official_last_name": "AHEARN",
"authorized_official_first_name": "PAMELA",
"authorized_official_middle_name": "E",
"authorized_official_title_or_position": "OWNER/PRESIDENT",
"authorized_official_telephone_number": "580-226-1010",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Family Medicine",
"state": "OK",
"license": "19862",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "PENDING",
"state": "OK"
}
],
"endpoints": [],
"other_names": []
}Other providers in Kingston, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 23, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.