1033164942 NPI number — LAKEWOOD HOSPITAL PROFESSIONAL SERVICES

Table of content: (NPI 1033164942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033164942 NPI number — LAKEWOOD HOSPITAL PROFESSIONAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEWOOD HOSPITAL PROFESSIONAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033164942
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20525 CENTER RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
ROCKY RIVER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44116-3437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-895-5021
Provider Business Mailing Address Fax Number:
440-895-5050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24700 LORAIN RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
NORTH OLMSTED
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44070-2088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-734-3494
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIEDT
Authorized Official First Name:
MARK
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
440-895-5021

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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