Organization
LAKESIDE PEDIATRIC & ADOLESCENT MEDICINE, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DIANA R VANHOOK (OFFICE MANAGER)
(208) 292-5437
Entity
Organization
Contact information
Practice address
980 W IRONWOOD DR, STE 302, COEUR D'ALENE, ID 83814-2601
(208) 292-5437
(208) 292-5441
Mailing address
980 W IRONWOOD DR, STE 302, COEUR D'ALENE, ID 83814-2601
(208) 292-5437
(208) 292-5441
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4010138351
REGENCE BLUE SHIELD GROUP
ID
05
—
806408200
—
ID
Enumeration date
12/06/2006
Last updated
07/12/2012
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