Provider Demographics
NPI:1215234638
Name:LAKE ERIE ANESTHESIA OF PA LLC
Entity type:Organization
Organization Name:LAKE ERIE ANESTHESIA OF PA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:814-835-2298
Mailing Address - Street 1:5529 SHADYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-6508
Mailing Address - Country:US
Mailing Address - Phone:814-835-2298
Mailing Address - Fax:
Practice Address - Street 1:5529 SHADYBROOK DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-6508
Practice Address - Country:US
Practice Address - Phone:814-835-2298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074658Medicaid
PA224377Medicare PIN
OH0074658Medicaid