NPIMap

Organization Active NPI

Lakeside North Family Medicine, LLC

  • Rural Health Clinic/Center
  • Guntersville, AL
National Provider Identifier
1891430583
Registry record updated Apr 28, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
LAKESIDE NORTH FAMILY MEDICINE, LLC
Practice address
38 Rowe Dr
Guntersville, AL 35976-7367
Phone
(256) 571-8460
Fax
(256) 571-8464
NPI assigned
Apr 28, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 28, 2022

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

Authorized official

Name
David Clay Campbell, MDNPI 1811100985
Title
President
Phone
(256) 571-8460

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

38 Rowe Dr
Guntersville, AL 35976-7367

Mailing address

38 Rowe Dr
Guntersville, AL 35976-7367
Phone (256) 571-8460

Other names 1

  • Lakeside North Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220601000364 AL Part A Provider - Rural Health Clinic 5395148530 Practice locations: Guntersville, AL

Rural health clinic certification: CCN 018960

Legal name
LAKESIDE NORTH FAMILY MEDICINE, LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 9, 2022
Last certification
Dec 9, 2022
Ownership / control type
2A
Organization structure
LLCProprietary
Incorporated
May 13, 2021 in AL
Enrollment address
38 Rowe Dr
Guntersville, AL 35976-7367

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Lakeside North2 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.

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
David C Campbell Individual 5% Or Greater Direct Ownership InterestMD/Owner Jun 3, 2021 100%
Operational/Managerial ControlMD/Owner Jun 3, 2021 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 7

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

NPI Registry JSON

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

{
    "created_epoch": "1651104000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1651104000000",
    "number": "1891430583",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "38 ROWE DR",
            "city": "GUNTERSVILLE",
            "state": "AL",
            "postal_code": "359767367",
            "telephone_number": "256-571-8460",
            "fax_number": "256-571-8464"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "38 ROWE DR",
            "city": "GUNTERSVILLE",
            "state": "AL",
            "postal_code": "359767367",
            "telephone_number": "256-571-8460",
            "fax_number": "256-571-8464"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESIDE NORTH FAMILY MEDICINE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-04-28",
        "last_updated": "2022-04-28",
        "certification_date": "2022-04-13",
        "status": "A",
        "authorized_official_last_name": "CAMPBELL",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "CLAY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "256-571-8460",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeside North",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Guntersville, AL

Sources for this page

Verify at the official NPI Registry.