Lakeside Surgery PA

Primary specialty

Surgery PhysicianTaxonomy code 208600000X

License

K6483 Issued in TX

Legal business name

LAKESIDE SURGERY PA

Practice address

4450 Tubbs Rd
Rockwall, TX 75032-6308

Phone

(972) 772-3290

Fax

(972) 722-3815

NPI assigned

Dec 21, 2011

Organization subpart

No

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

Authorized official

Name

Terri R Phillip

Title

Practice Manager

Phone

(972) 722-3290

Specialties & licenses 3

Addresses

Other identifiers 5

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

Tax ID family

Kenneth L Bryce MD PA2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

• Lakeside Surgery, P.a.

  • Specialist
  • Rockwall, TX
  • NPI 1851489520
  NPD tax ID

Locations

Practitioners 4

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

• Caraleigh Nicole Buxie, MD

  • Surgery Physician
  • Rockwall, TX
  • NPI 1952577546
  Medicare reassignment NPD
• Katherine R Makohon, M.D.

  • Surgery Physician
  • Rockwall, TX
  • NPI 1952393415
  Medicare reassignment NPD
• Jeffrey S Stephens, M.D.

  • Specialist
  • Rockwall, TX
  • NPI 1326097676

  Surgery

  Medicare reassignment NPD
• Kiran Sethi Venincasa, M.D.

  • Surgery Physician
  • Irving, TX
  • NPI 1821477274
  Medicare reassignment NPD

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

{
    "created_epoch": "1324425600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1529452800000",
    "number": "1831468800",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4450 TUBBS RD",
            "city": "ROCKWALL",
            "state": "TX",
            "postal_code": "750326308",
            "telephone_number": "972-722-3290",
            "fax_number": "972-722-3815"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4450 TUBBS RD",
            "city": "ROCKWALL",
            "state": "TX",
            "postal_code": "750326308",
            "telephone_number": "972-772-3290",
            "fax_number": "972-722-3815"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESIDE SURGERY PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-12-21",
        "last_updated": "2018-06-20",
        "status": "A",
        "authorized_official_last_name": "PHILLIP",
        "authorized_official_first_name": "TERRI",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "972-722-3290"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Surgery",
            "state": "TX",
            "license": "K6483",
            "primary": true
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Surgery",
            "state": "TX",
            "license": "J2983",
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Surgery",
            "state": "TX",
            "license": "P6593",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI #",
            "identifier": "1326097676",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI #",
            "identifier": "1952393415",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TX LICENSE",
            "identifier": "J2983",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TX LICENSE",
            "identifier": "K6483",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE",
            "identifier": "P6593",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Lakepointe SCC LLC
• Lakeshore Dental PLLC
• Lakeside Allergy ENT LLP
• Lakeside Dental Sleep Associates LLC
• Lakeside Family Health Care PLLC
• Lakeside Surgery, P.a.
• Lakeview TMS Center PLLC
• Brandy Lancione
• Christine Lanford
• Craig Brandon Lankford, M.D.

• Surgery Physician in Rockwall, TX
• Providers in Rockwall, TX by specialty
• Surgery Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2018; 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.

Verify at the official NPI Registry.