Provider Demographics
NPI:1073500930
Name:LAKE PARK SURGICARE, LLC
Entity Type:Organization
Organization Name:LAKE PARK SURGICARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKSIMOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-942-9600
Mailing Address - Street 1:7921 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6663
Mailing Address - Country:US
Mailing Address - Phone:219-942-9600
Mailing Address - Fax:219-947-9922
Practice Address - Street 1:7921 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6663
Practice Address - Country:US
Practice Address - Phone:219-942-9600
Practice Address - Fax:219-947-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QA1903X261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000191299OtherBLUE CROSS
INZH2050Medicare ID - Type Unspecified