Provider Demographics
NPI:1417030982
Name:LAKESIDE HEART AND LUNG CENTER, INC.
Entity Type:Organization
Organization Name:LAKESIDE HEART AND LUNG CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DERISO
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:419-609-8000
Mailing Address - Street 1:703 TYLER ST
Mailing Address - Street 2:STE 252
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-3367
Mailing Address - Country:US
Mailing Address - Phone:419-609-8000
Mailing Address - Fax:419-609-8002
Practice Address - Street 1:703 TYLER ST
Practice Address - Street 2:STUITE 252
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3367
Practice Address - Country:US
Practice Address - Phone:419-609-8000
Practice Address - Fax:419-609-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0883469Medicaid
OHF27453Medicare UPIN
OH0883469Medicaid