Basic Information
| Provider Information | |||||||||
| NPI: | 1710946785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE COUNTY AND WEST EKG ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30701 LORAIN RD STE A | ||||||||
| Address2: | |||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440706325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402745000 | ||||||||
| FaxNumber: | 4407168608 | ||||||||
| Practice Location | |||||||||
| Address1: | 7500 AUBURN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PAINESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440779602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403522754 | ||||||||
| FaxNumber: | 4403520330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 09/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | BANNA | ||||||||
| AuthorizedOfficialFirstName: | M | ||||||||
| AuthorizedOfficialMiddleName: | AHMAD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4403585555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0813794 | 05 | OH | MEDICAID | 18958 | 01 | OH | QUALCHOICE | OTHER | 2597481 | 01 | OH | UNITED HEALTHCARE | OTHER | CK1332 | 01 | OH | RAILROAD MEDICARE B | OTHER | 264168 | 01 | OH | FEDERAL BLACK LUNG | OTHER |