Provider Demographics
NPI:1942489257
Name:LAKEWOOD AMBULATORY FOOT CEN
Entity Type:Organization
Organization Name:LAKEWOOD AMBULATORY FOOT CEN
Other - Org Name:LAKEWOOD AMBULATORY FOOT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SMIK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-941-0233
Mailing Address - Street 1:3386 WARREN RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-2031
Mailing Address - Country:US
Mailing Address - Phone:216-941-0233
Mailing Address - Fax:216-941-0235
Practice Address - Street 1:3386 WARREN ROAD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-0000
Practice Address - Country:US
Practice Address - Phone:216-941-0233
Practice Address - Fax:216-941-0235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002511261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0740336Medicaid
OHCL1324OtherRAILROAD MEDICARE
OH0597560001Medicare NSC
OHT91555Medicare UPIN