Provider Demographics
NPI:1275673865
Name:LAKE SURGICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:LAKE SURGICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:PELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-922-0222
Mailing Address - Street 1:10110 DONALD POWERS DR.
Mailing Address - Street 2:STE. 202
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321
Mailing Address - Country:US
Mailing Address - Phone:219-922-0222
Mailing Address - Fax:219-922-8899
Practice Address - Street 1:10110 DONALD POWERS DR.
Practice Address - Street 2:STE. 202
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321
Practice Address - Country:US
Practice Address - Phone:219-922-0222
Practice Address - Fax:219-922-8899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL90001007OtherBLUE SHIELD IL
INCH5506OtherRRMEDICARE
IL90001007OtherBLUE SHIELD IL