Organization
LAKESIDE SURGERY PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TERRI R PHILLIP (PRACTICE MANAGER)
(972) 722-3290
Entity
Organization
Contact information
Practice address
4450 TUBBS RD, ROCKWALL, TX 75032-6308
(972) 772-3290
(972) 722-3815
Mailing address
4450 TUBBS RD, ROCKWALL, TX 75032-6308
(972) 722-3290
(972) 722-3815
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
J2983
TX
208600000X
Surgery Physician
Primary
K6483
TX
208600000X
Surgery Physician
P6593
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1326097676
NPI #
TX
01
—
1952393415
NPI #
TX
01
—
J2983
TX LICENSE
TX
01
—
K6483
TX LICENSE
TX
01
—
P6593
STATE LICENSE
TX
Enumeration date
12/21/2011
Last updated
06/20/2018
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