Provider Demographics
NPI:1619114097
Name:LAKE PEDIATRICS PC
Entity Type:Organization
Organization Name:LAKE PEDIATRICS PC
Other - Org Name:OLD SCHOOLHOUSE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-893-2364
Mailing Address - Street 1:373 MERIDIAN PARKE LN
Mailing Address - Street 2:STE. E
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9420
Mailing Address - Country:US
Mailing Address - Phone:317-893-2364
Mailing Address - Fax:317-851-8066
Practice Address - Street 1:373 MERIDIAN PARKE LN
Practice Address - Street 2:STE. E
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9420
Practice Address - Country:US
Practice Address - Phone:317-893-2364
Practice Address - Fax:317-851-8066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200928110AMedicaid
IN50005045AOtherMEDICAL CORPORATION LICENSE