Lakeshore Pediatrics PC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

License

17108 Issued in AL

Legal business name

LAKESHORE PEDIATRICS PC

Practice address

12521 Al Highway 157 Ste B
Moulton, AL 35650-1937

Phone

(256) 974-6300

NPI assigned

Jul 22, 2013

Last updated

Jul 22, 2013By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Agustin Rivas, MD

Title

Owner

Phone

(256) 386-4151

Specialties & licenses 1

Addresses

Other identifiers 1

Tax ID family

Lakeshore Pediatrics PC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

• Lakeshore Pediatrics P.C.

  • Pediatrics Physician
  • Sheffield, AL
  • NPI 1447358619
  NPD tax ID
• Lakeshore Pediatrics PC

  • Pediatrics Physician
  • Moulton, AL
  • NPI 1588002455
  NPD tax ID

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

{
    "created_epoch": "1374451200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1374451200000",
    "number": "1801238787",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1120 S JACKSON HWY STE 304",
            "city": "SHEFFIELD",
            "state": "AL",
            "postal_code": "356605773",
            "telephone_number": "256-386-4151"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12521 AL HIGHWAY 157 STE B",
            "city": "MOULTON",
            "state": "AL",
            "postal_code": "356501937",
            "telephone_number": "256-974-6300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESHORE PEDIATRICS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-07-22",
        "last_updated": "2013-07-22",
        "status": "A",
        "authorized_official_last_name": "RIVAS",
        "authorized_official_first_name": "AGUSTIN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "256-386-4151",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "AL",
            "license": "17108",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1588002455",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brett Lee Kelley
• Kari Kirby, CRNP
• Adeniyi Faruk Koiki, M.D.
• Rebecca Lackey
• Lakeshore Pediatrics PC
• Lawrence County
• Lawrence County E.M.S., Inc. (Greg's Ambulance Service)
• Lawrence County Emergency Medical Services, Inc. (Greg's Ambulance Service)
• Lawrence County Health Dept Adult Immun
• Lawrence County Health Dept AIDS

• Rural Health Clinic/Center in Moulton, AL
• Providers in Moulton, AL by specialty
• Rural Health Clinic/Center in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2013; 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.