Provider Demographics
NPI:1417119223
Name:LAKEFRONT MEDICAL CENTER PA
Entity Type:Organization
Organization Name:LAKEFRONT MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:VARRAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-841-0084
Mailing Address - Street 1:60 W COLUMBIA ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1126
Mailing Address - Country:US
Mailing Address - Phone:407-841-0084
Mailing Address - Fax:407-423-4406
Practice Address - Street 1:60 W COLUMBIA ST
Practice Address - Street 2:SUITE F
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1126
Practice Address - Country:US
Practice Address - Phone:407-841-0084
Practice Address - Fax:407-423-4406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0031947174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77907Medicare PIN