Lakeside Internal Medicine PC

Primary specialty

Primary Care Clinic/CenterTaxonomy code 261QP2300X

License

4301058249 Issued in MI

Legal business name

LAKESIDE INTERNAL MEDICINE PC

Practice address

21519 Harper Ave Ste 109
Saint Clair Shores, MI 48080-2209

Phone

(586) 945-5012

NPI assigned

Jun 25, 2007

Organization subpart

No

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

Authorized official

Name

Paul Antony

Title

President

Phone

(586) 778-5287

Specialties & licenses 1

Addresses

Other identifiers 1

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

{
    "created_epoch": "1182729600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1408320000000",
    "number": "1386840502",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21519 HARPER AVE",
            "address_2": "SUITE 109",
            "city": "SAINT CLAIR SHORES",
            "state": "MI",
            "postal_code": "480802220",
            "telephone_number": "586-447-3017"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21519 HARPER AVE STE 109",
            "city": "SAINT CLAIR SHORES",
            "state": "MI",
            "postal_code": "480802209",
            "telephone_number": "586-945-5012"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESIDE INTERNAL MEDICINE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-25",
        "last_updated": "2014-08-18",
        "status": "A",
        "authorized_official_last_name": "ANTONY",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "586-778-5287"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "MI",
            "license": "4301058249",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5199450",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Primary Care Clinic/Center in Saint Clair Shores, MI
• Providers in Saint Clair Shores, MI by specialty
• Primary Care Clinic/Center in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 18, 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.