Provider Demographics
NPI:1174659262
Name:LAKE ORTHOPEDIC GROUP, INC.
Entity type:Organization
Organization Name:LAKE ORTHOPEDIC GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:HOEFT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-348-4432
Mailing Address - Street 1:1057 MEDICAL PARK DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065
Mailing Address - Country:US
Mailing Address - Phone:573-348-4432
Mailing Address - Fax:573-348-9410
Practice Address - Street 1:1057 MEDICAL PARK DR
Practice Address - Street 2:SUITE C
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065
Practice Address - Country:US
Practice Address - Phone:573-348-4432
Practice Address - Fax:573-348-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7F70207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F42617Medicare UPIN
CT1007Medicare PIN