Provider Demographics
NPI:1497740617
Name:LAKE COUNTY PAIN & DIAGNOSTIC
Entity Type:Organization
Organization Name:LAKE COUNTY PAIN & DIAGNOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:T
Authorized Official - Last Name:BOYLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-205-9119
Mailing Address - Street 1:9485 MENTOR AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8723
Mailing Address - Country:US
Mailing Address - Phone:440-205-9119
Mailing Address - Fax:440-205-9209
Practice Address - Street 1:8401 MENTOR AVE
Practice Address - Street 2:STE A
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5842
Practice Address - Country:US
Practice Address - Phone:440-205-9119
Practice Address - Fax:440-205-9209
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATRICK T. BOYLAN, MD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-14
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0743A5261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3611981Medicare ID - Type Unspecified