1942489257 NPI number — LAKEWOOD AMBULATORY FOOT CEN

Table of content: (NPI 1942489257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942489257 NPI number — LAKEWOOD AMBULATORY FOOT CEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEWOOD AMBULATORY FOOT CEN
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:
LAKEWOOD AMBULATORY FOOT CENTER
Provider Other Organization Name Type Code:
3
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:
1942489257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3386 WARREN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44111-2031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-941-0233
Provider Business Mailing Address Fax Number:
216-941-0235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3386 WARREN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44111-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-941-0233
Provider Business Practice Location Address Fax Number:
216-941-0235
Provider Enumeration Date:
11/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMIK
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
216-941-0233

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  36002511 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0740336 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: CL1324 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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