Provider Demographics
NPI:1124111992
Name:LAKE ERIE MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:LAKE ERIE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:H
Authorized Official - Last Name:STARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-598-8880
Mailing Address - Street 1:1128 W PLEASANT VALLEY RD
Mailing Address - Street 2:#107
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-6711
Mailing Address - Country:US
Mailing Address - Phone:216-328-2086
Mailing Address - Fax:216-328-8091
Practice Address - Street 1:6701 ROCKSIDE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44131-2358
Practice Address - Country:US
Practice Address - Phone:216-328-8086
Practice Address - Fax:216-328-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherEIN