Provider Demographics
NPI:1922799378
Name:LAKE COUNTY INTERNAL MEDICINE, INC.
Entity Type:Organization
Organization Name:LAKE COUNTY INTERNAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAITHAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-681-0300
Mailing Address - Street 1:587 CHARLES PL
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-1949
Mailing Address - Country:US
Mailing Address - Phone:440-681-0300
Mailing Address - Fax:
Practice Address - Street 1:9485 MENTOR AVE STE 104
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8722
Practice Address - Country:US
Practice Address - Phone:440-205-5770
Practice Address - Fax:440-701-6143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty