Provider Demographics
NPI:1124235346
Name:LAKE ENT INC
Entity type:Organization
Organization Name:LAKE ENT INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:
Authorized Official - Last Name:AZEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-942-9308
Mailing Address - Street 1:36100 EUCLID AVE
Mailing Address - Street 2:#350
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4456
Mailing Address - Country:US
Mailing Address - Phone:440-942-9308
Mailing Address - Fax:440-942-8981
Practice Address - Street 1:36100 EUCLID AVE
Practice Address - Street 2:#350
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4456
Practice Address - Country:US
Practice Address - Phone:440-942-9308
Practice Address - Fax:440-942-8981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH054514207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0652575Medicaid
OH351443601003OtherMEDICAL MUTUAL
OH000000131755OtherBLUE CROSS BLUE SHIELD
OHA16783Medicare UPIN
OH0594477Medicare ID - Type Unspecified