Provider Demographics
NPI:1669565578
Name:LAKEWOOD PEDIATRICS
Entity type:Organization
Organization Name:LAKEWOOD PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.O./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:PEARLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:216-227-1330
Mailing Address - Street 1:14701 DETROIT AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4115
Mailing Address - Country:US
Mailing Address - Phone:216-227-1330
Mailing Address - Fax:216-227-1322
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4115
Practice Address - Country:US
Practice Address - Phone:216-227-1330
Practice Address - Fax:216-227-1322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004965208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0834379Medicaid
OH0834379Medicaid