Provider Demographics
NPI:1104819457
Name:CITY OF LAKEWOOD - DIVISION OF HEALTH
Entity type:Organization
Organization Name:CITY OF LAKEWOOD - DIVISION OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH COMMISSIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-529-7693
Mailing Address - Street 1:12805 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-2835
Mailing Address - Country:US
Mailing Address - Phone:216-529-7690
Mailing Address - Fax:216-529-5910
Practice Address - Street 1:12805 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-2835
Practice Address - Country:US
Practice Address - Phone:216-529-7690
Practice Address - Fax:216-529-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0874237Medicaid
OHFV 90091Medicare ID - Type Unspecified