Healthcare Provider Details

I. General information

NPI: 1548210560
Provider Name (Legal Business Name): LAKESHORE ANESTHESIA, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S LAKE PARK AVE
HOBART IN
46342-6638
US

IV. Provider business mailing address

PO BOX 11581
FORT WAYNE IN
46859-1581
US

V. Phone/Fax

Practice location:
  • Phone: 219-942-0551
  • Fax:
Mailing address:
  • Phone: 219-267-0094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEREK CHEUK
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 219-267-0094