Provider Demographics
NPI:1154606101
Name:LAKESHORE EMS
Entity type:Organization
Organization Name:LAKESHORE EMS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-945-3607
Mailing Address - Street 1:3480 E 83RD PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6547
Mailing Address - Country:US
Mailing Address - Phone:219-663-2896
Mailing Address - Fax:219-794-1077
Practice Address - Street 1:3480 E 83RD PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6547
Practice Address - Country:US
Practice Address - Phone:219-663-2896
Practice Address - Fax:219-794-1077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201135230Medicaid