MEDICARE: LAKES ANESTHESIA, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1144261967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKES ANESTHESIA, PLC

Provider Business Mailing Address
First Line	:	255 W MICHIGAN AVE
Second Line	:	PO BOX 1123
City	:	JACKSON
State	:	MI
Zip	:	49201-2218
Country	:	US
Telephone Number	:	517-787-6440
Fax Number	:	517-787-4146

Provider Business Practice Location Address
First Line	:	28500 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-2936
Country	:	US
Telephone Number	:	248-851-6767
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	DR. ROBERT TAWIL
Credential	:	MD
Telephone Number	:	248-896-6300

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	10/11/2008

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