Basic Information
| Provider Information | |||||||||
| NPI: | 1972541837 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKEWOOD HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKEWOOD HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6801 BRECKSVILLE RD | ||||||||
| Address2: | SUITE 20 RK10 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441315032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166368051 | ||||||||
| FaxNumber: | 2166368088 | ||||||||
| Practice Location | |||||||||
| Address1: | 14519 DETROIT AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441074316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165214200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 09/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | GLASS | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2164449361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 1134 | OH | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 521890 | 01 | AETNA | OTHER | 5000096 | 01 | UNITED HEALTHCARE | OTHER | 000000157342 | 01 | ANTHEM | OTHER |