Provider Demographics
NPI:1487779435
Name:LAKEFOREST AMBULATORY SURGERY CENTER
Entity type:Organization
Organization Name:LAKEFOREST AMBULATORY SURGERY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:MICHETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-948-3668
Mailing Address - Street 1:702 RUSSELL AVE
Mailing Address - Street 2:#301
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2606
Mailing Address - Country:US
Mailing Address - Phone:301-948-3668
Mailing Address - Fax:301-926-7787
Practice Address - Street 1:702 RUSSELL AVE
Practice Address - Street 2:#301
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2606
Practice Address - Country:US
Practice Address - Phone:301-948-3668
Practice Address - Fax:301-926-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1136261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
309595OtherMEDICARE PROVIDER #
MDA1136OtherMARYLAND LICENSE
309597OtherMEDICARE PROVIDER # DH