1033164942 NPI number — LAKEWOOD HOSPITAL PROFESSIONAL SERVICES

Table of Contents

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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