Provider Demographics
NPI:1487709713
Name:LAKESIDE SURGICAL ASSOCIATES, PA
Entity type:Organization
Organization Name:LAKESIDE SURGICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:M D, FACS
Authorized Official - Phone:704-664-6677
Mailing Address - Street 1:150 FAIRVIEW RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9504
Mailing Address - Country:US
Mailing Address - Phone:704-664-6677
Mailing Address - Fax:704-663-1009
Practice Address - Street 1:150 FAIRVIEW RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9504
Practice Address - Country:US
Practice Address - Phone:704-664-6677
Practice Address - Fax:704-663-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8938320Medicaid
NC8938320Medicaid