Healthcare Provider Details

I. General information

NPI: 1326202086
Provider Name (Legal Business Name): LAKEFOREST AMBULATORY SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 MARLBORO PIKE
DISTRICT HEIGHTS MD
20747-2841
US

IV. Provider business mailing address

702 RUSSELL AVE SUITE 103
GAITHERSBURG MD
20877-2606
US

V. Phone/Fax

Practice location:
  • Phone: 301-736-6900
  • Fax: 301-736-7180
Mailing address:
  • Phone: 301-948-3668
  • Fax: 301-926-7787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA1136
License Number StateMD

VIII. Authorized Official

Name: DR. MICHAEL LAWRENCE MICHETTI
Title or Position: MEDICAL DIRECTOR AND OWNER
Credential: DPM
Phone: 301-948-3668