1487779435 NPI number — LAKEFOREST AMBULATORY SURGERY CENTER

Table of content: (NPI 1487779435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487779435 NPI number — LAKEFOREST AMBULATORY SURGERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEFOREST AMBULATORY SURGERY CENTER
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:
6
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:
1487779435
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:
702 RUSSELL AVE
Provider Second Line Business Mailing Address:
#301
Provider Business Mailing Address City Name:
GAITHERSBURG
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20877-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-948-3668
Provider Business Mailing Address Fax Number:
301-926-7787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 RUSSELL AVE
Provider Second Line Business Practice Location Address:
#301
Provider Business Practice Location Address City Name:
GAITHERSBURG
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20877-2606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-948-3668
Provider Business Practice Location Address Fax Number:
301-926-7787
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MICHETTI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
LAWRENCE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
301-948-3668

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  A1136 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 309595 . This is a "MEDICARE PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: A1136 . This is a "MARYLAND LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 309597 . This is a "MEDICARE PROVIDER # DH" identifier . This identifiers is of the category "OTHER".




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