Provider Demographics
NPI:1902137417
Name:LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Entity Type:Organization
Organization Name:LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:BINDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-505-5555
Mailing Address - Street 1:25 RIVIERA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5694
Mailing Address - Country:US
Mailing Address - Phone:928-505-5555
Mailing Address - Fax:928-505-2877
Practice Address - Street 1:150 EAST TYSON RD
Practice Address - Street 2:
Practice Address - City:QUARTZSITE
Practice Address - State:AZ
Practice Address - Zip Code:85359
Practice Address - Country:US
Practice Address - Phone:928-505-5555
Practice Address - Fax:928-505-2877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13802207X00000X
AZ23186207X00000X
AZ34564207X00000X
AZ26379207X00000X
AZ0554213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ110835Medicare PIN
AZ5924960003Medicare NSC