Provider Demographics
NPI:1619921681
Name:LAKEWOOD HOSPITAL PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:LAKEWOOD HOSPITAL PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WIEDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-895-5021
Mailing Address - Street 1:20525 CENTER RIDGE RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-3437
Mailing Address - Country:US
Mailing Address - Phone:440-895-5021
Mailing Address - Fax:440-895-5050
Practice Address - Street 1:1730 W 25TH ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3108
Practice Address - Country:US
Practice Address - Phone:216-771-4455
Practice Address - Fax:216-241-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty