Provider Demographics
NPI:1750395661
Name:LAKE COUNTRY SURGICAL, PLC
Entity type:Organization
Organization Name:LAKE COUNTRY SURGICAL, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:TOZZI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:434-447-4736
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0850
Mailing Address - Country:US
Mailing Address - Phone:434-447-4736
Mailing Address - Fax:434-447-4810
Practice Address - Street 1:416 BRACEY LN
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1631
Practice Address - Country:US
Practice Address - Phone:434-447-4736
Practice Address - Fax:434-447-4810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102200839208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007313365Medicaid
VAC08557Medicare ID - Type Unspecified
VAG99408Medicare UPIN