# LAKESIDE FAMILY PRACTICE PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1205919917
- **Authorized official:** DR. BRIAN W HAWTHORNE M.D. (PRESIDENT)
- **Authorized official phone:** (304) 594-2400

## Contact information

- **Practice address:** 933 CHEAT RD, MORGANTOWN, WV 26508-5631
- **Practice address phone:** (304) 594-2400
- **Practice address fax:** (304) 594-2256
- **Mailing address:** 933 CHEAT RD, MORGANTOWN, WV 26508-5631
- **Mailing address phone:** (304) 594-2400
- **Mailing address fax:** (304) 594-2256

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 10/24/2006
- **Last updated:** 05/09/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 001709238 | BLUE SHIELD GROUP PROVIDE | WV |
| 05 | — | 3810002243 | — | WV |