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General NPI Number Information
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NPI Number | 1275673865
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Entity Type | Organization
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Legal Business Name | LAKE SURGICAL ASSOCIATES, LLC
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 03/19/2008
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Provider Practice Location Address
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Address Line | 10110 DONALD POWERS DR. STE. 202
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City | MUNSTER
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State | IN
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Zip | 46321
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Country | US
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Telephone | 219-922-0222
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Fax | 219-922-8899
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Provider Business Mailing Address
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Address Line | 10110 DONALD POWERS DR. STE. 202
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City | MUNSTER
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State | IN
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Zip | 46321
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Country | US
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Telephone | 219-922-0222
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Fax | 219-922-8899
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. RUSSELL W PELLAR
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Credential | M.D.
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Telephone | 219-922-0222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State | IN
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