| Lakeside Family Medicine | |
|
21 N. Main Street Kingston OK 73439-1798 | |
| (580) 226-1010 | |
| Not Available |
| Full Name | Lakeside Family Medicine |
|---|---|
| Speciality | Family Medicine |
| Location | 21 N. Main Street, Kingston, Oklahoma |
| Authorized Official Name and Position | Pamela E Ahearn (OWNER/PRESIDENT) |
| Authorized Official Contact | 5802261010 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lakeside Family Medicine Po Box 1798 Kingston OK 73439-1798 Ph: (580) 226-1010 | Lakeside Family Medicine 21 N. Main Street Kingston OK 73439-1798 Ph: (580) 226-1010 |
| NPI Number | 1295064178 |
|---|---|
| Provider Enumeration Date | 12/23/2009 |
| Last Update Date | 12/23/2009 |
| Medicare PECOS PAC ID | 6204971112 |
|---|---|
| Medicare Enrollment ID | O20100303000625 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1295064178 | NPI | - | NPPES |
| PENDING | Medicaid | OK |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 19862 (Oklahoma) | Primary |
| Provider Name | Imran Aaron Michale Plumb |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1275827305 PECOS PAC ID: 9032434659 Enrollment ID: I20150202001697 |
| Provider Name | Katie L Green |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1205296795 PECOS PAC ID: 4183914914 Enrollment ID: I20160607000063 |
| Provider Name | Amy Lee Goedecke |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1952776890 PECOS PAC ID: 7012043433 Enrollment ID: I20180918002788 |
| Provider Name | Meghan Fomby |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1831505023 PECOS PAC ID: 7214245364 Enrollment ID: I20181109001633 |
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