Healthcare Provider Details

I. General information

NPI: 1275673865
Provider Name (Legal Business Name): LAKE SURGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 DONALD POWERS DR. STE. 202
MUNSTER IN
46321
US

IV. Provider business mailing address

10110 DONALD POWERS DR. STE. 202
MUNSTER IN
46321
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-0222
  • Fax: 219-922-8899
Mailing address:
  • Phone: 219-922-0222
  • Fax: 219-922-8899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. RUSSELL W PELLAR
Title or Position: DOCTOR
Credential: M.D.
Phone: 219-922-0222