1275673865 NPI number — LAKE SURGICAL ASSOCIATES, LLC

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 1275673865 NPI number — LAKE SURGICAL ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE SURGICAL ASSOCIATES, LLC
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:
1275673865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10110 DONALD POWERS DR.
Provider Second Line Business Mailing Address:
STE. 202
Provider Business Mailing Address City Name:
MUNSTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-922-0222
Provider Business Mailing Address Fax Number:
219-922-8899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10110 DONALD POWERS DR.
Provider Second Line Business Practice Location Address:
STE. 202
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-922-0222
Provider Business Practice Location Address Fax Number:
219-922-8899
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PELLAR
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
219-922-0222

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 90001007 . This is a "BLUE SHIELD IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CH5506 . This is a "RRMEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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