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General NPI Number Information
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NPI Number | 1275603722
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Entity Type | Organization
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Legal Business Name | GAHANNA MEDICAL PRACTICES INC
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 07/19/2012
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Provider Practice Location Address
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Address Line | 4550 N HAMILTON RD
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City | GAHANNA
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State | OH
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Zip | 43230
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Country | US
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Telephone | 614-428-8200
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Fax | 614-428-9700
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Provider Business Mailing Address
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Address Line | 4550 N HAMILTON RD
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City | GAHANNA
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State | OH
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Zip | 43230
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Country | US
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Telephone | 614-428-8200
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Fax | 614-428-9700
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. SUSAN E LAKE
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Credential | DO
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Telephone | 614-428-8200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 34005856
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License Number State | OH
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