Provider Demographics
NPI:1548210560
Name:LAKESHORE ANESTHESIA, P.C.
Entity Type:Organization
Organization Name:LAKESHORE ANESTHESIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-267-0094
Mailing Address - Street 1:PO BOX 11581
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46859-1581
Mailing Address - Country:US
Mailing Address - Phone:219-267-0094
Mailing Address - Fax:
Practice Address - Street 1:1500 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6638
Practice Address - Country:US
Practice Address - Phone:219-942-0551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196230Medicaid
IN200196230Medicaid