MEDICARE: LAKEWOOD HOSPITAL PROFESSIONAL SERVICES

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1619921681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKEWOOD HOSPITAL PROFESSIONAL SERVICES

Provider Business Mailing Address
First Line	:	20525 CENTER RIDGE RD
Second Line	:	SUITE 220
City	:	ROCKY RIVER
State	:	OH
Zip	:	44116-3437
Country	:	US
Telephone Number	:	440-895-5021
Fax Number	:	440-895-5050

Provider Business Practice Location Address
First Line	:	1730 W 25TH ST
Second Line	:	SUITE 1100
City	:	CLEVELAND
State	:	OH
Zip	:	44113-3108
Country	:	US
Telephone Number	:	216-771-4455
Fax Number	:	216-241-1569

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. MARK E WIEDT
Credential	:
Telephone Number	:	440-895-5021

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	08/22/2020

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