1922164409 NPI number — LAKE ERIE PODIATRY, 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 1922164409 NPI number — LAKE ERIE PODIATRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE ERIE PODIATRY, 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:
1922164409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3910 CAUGHEY RD STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16506-4097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-833-3668
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3910 CAUGHEY RD STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-833-3668
Provider Business Practice Location Address Fax Number:
888-329-6120
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUIZ
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
814-833-3668

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  SC004630L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 480035188 . This is a "MEDICARE RRB" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0019415170002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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