MEDICARE: LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1467087296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE

Provider Business Mailing Address
First Line	:	2828 S MCCALL RD STE 21
Second Line	:
City	:	ENGLEWOOD
State	:	FL
Zip	:	34224-9517
Country	:	US
Telephone Number	:	941-474-8154
Fax Number	:

Provider Business Practice Location Address
First Line	:	2828 S MCCALL RD STE 21
Second Line	:
City	:	ENGLEWOOD
State	:	FL
Zip	:	34224-9517
Country	:	US
Telephone Number	:	941-474-8154
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORIDATOR
Name	:	TATIANA ROBLES
Credential	:
Telephone Number	:	239-348-5080

Provider Enumeration Date	:	03/12/2020
Last Update Date	:	03/12/2020

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