Basic Information
| Provider Information | |||||||||
| NPI: | 1487779435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKEFOREST AMBULATORY SURGERY CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DISTRICT HEIGHTS AMBULATORY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 702 RUSSELL AVE | ||||||||
| Address2: | #301 | ||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208772606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019483668 | ||||||||
| FaxNumber: | 3019267787 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 RUSSELL AVE | ||||||||
| Address2: | #301 | ||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208772606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019483668 | ||||||||
| FaxNumber: | 3019267787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MICHETTI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | LAWRENCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3019483668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| 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 |
ID Information
| ID | Type | State | Issuer | Description | 309595 | 01 | MEDICARE PROVIDER # | OTHER | A1136 | 01 | MD | MARYLAND LICENSE | OTHER | 309597 | 01 | MEDICARE PROVIDER # DH | OTHER |