Provider Demographics
NPI:1356394357
Name:LAKE HEALTH-UNIVERSITY HOSPITALS SEIDMAN CANCER CTR PHYSICIANS INC
Entity type:Organization
Organization Name:LAKE HEALTH-UNIVERSITY HOSPITALS SEIDMAN CANCER CTR PHYSICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-205-5759
Mailing Address - Street 1:9485 MENTOR AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8711
Mailing Address - Country:US
Mailing Address - Phone:440-205-5755
Mailing Address - Fax:440-205-5743
Practice Address - Street 1:9485 MENTOR AVE STE 3
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8711
Practice Address - Country:US
Practice Address - Phone:440-205-5775
Practice Address - Fax:440-205-5733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0003X, 3336C0003X
OH0210348003336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144250OtherPK
OH2560590Medicaid
2144250OtherPK
OH2560590Medicaid