MEDICARE: LAKEWOOD SURGICAL ASSOCIATES LP

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	174400000X	Specialist

General Provider Information

NPI Number	:	1538415260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKEWOOD SURGICAL ASSOCIATES LP

Provider Business Mailing Address
First Line	:	9219 GARLAND RD STE 2107
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75218-4639
Country	:	US
Telephone Number	:	469-547-6170
Fax Number	:	469-547-6180

Provider Business Practice Location Address
First Line	:	9219 GARLAND RD STE 2107
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75218-4639
Country	:	US
Telephone Number	:	469-547-6170
Fax Number	:	469-547-6180

Authorized Official
Title or Position	:	PA-C
Name	:	HAILEY HOSAK
Credential	:
Telephone Number	:	469-547-6170

Provider Enumeration Date	:	07/31/2012
Last Update Date	:	07/31/2012

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