Provider Demographics
NPI:1144406133
Name:LAKE PLASTICE SURGEONS ,INC
Entity Type:Organization
Organization Name:LAKE PLASTICE SURGEONS ,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-953-1818
Mailing Address - Street 1:36100 EUCLID AVE STE 490
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4488
Mailing Address - Country:US
Mailing Address - Phone:440-953-1818
Mailing Address - Fax:
Practice Address - Street 1:36100 EUCLID AVE STE 490
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4488
Practice Address - Country:US
Practice Address - Phone:440-953-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA9276981Medicare PIN