Provider Demographics
NPI:1922164409
Name:LAKE ERIE PODIATRY, LLC
Entity Type:Organization
Organization Name:LAKE ERIE PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:814-833-3668
Mailing Address - Street 1:3910 CAUGHEY RD STE 130
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4097
Mailing Address - Country:US
Mailing Address - Phone:814-833-3668
Mailing Address - Fax:
Practice Address - Street 1:3910 CAUGHEY RD STE 130
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506
Practice Address - Country:US
Practice Address - Phone:814-833-3668
Practice Address - Fax:888-329-6120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004630L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA480035188OtherMEDICARE RRB
PA0019415170002Medicaid
PA480035188OtherMEDICARE RRB
PA0019415170002Medicaid