Healthcare Provider Details

I. General information

NPI: 1811950447
Provider Name (Legal Business Name): LAKE OBSTETRICS AND GYNECOLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 TYLER BLVD STE 300
MENTOR OH
44060-4251
US

IV. Provider business mailing address

8300 TYLER BLVD STE 300
MENTOR OH
44060-4251
US

V. Phone/Fax

Practice location:
  • Phone: 440-557-7100
  • Fax:
Mailing address:
  • Phone: 440-357-7100
  • Fax: 440-357-8136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSANNA BOWMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 440-357-7100