Provider Demographics
NPI:1528006616
Name:LAKE CARDIOLOGY INC
Entity Type:Organization
Organization Name:LAKE CARDIOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-352-4956
Mailing Address - Street 1:124 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3303
Mailing Address - Country:US
Mailing Address - Phone:440-352-4956
Mailing Address - Fax:440-352-0397
Practice Address - Street 1:124 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3303
Practice Address - Country:US
Practice Address - Phone:440-352-4956
Practice Address - Fax:440-352-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9926054Medicare PIN
OH9926053Medicare PIN