Basic Information
| Provider Information | |||||||||
| NPI: | 1326202086 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKEFOREST AMBULATORY SURGERY CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DISTRICT HEIGHTS AMBULATORY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 RUSSELL AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208772606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019483668 | ||||||||
| FaxNumber: | 3019267787 | ||||||||
| Practice Location | |||||||||
| Address1: | 6400 MARLBORO PIKE | ||||||||
| Address2: | |||||||||
| City: | DISTRICT HEIGHTS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207472841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017366900 | ||||||||
| FaxNumber: | 3017367180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | MICHETTI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | LAWRENCE | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR AND OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3019483668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | A1136 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.