Provider Demographics
NPI:1730192097
Name:LAKOTA MEDICAL, LLC
Entity type:Organization
Organization Name:LAKOTA MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:513-893-8000
Mailing Address - Street 1:2466 TENNYSON DR
Mailing Address - Street 2:
Mailing Address - City:BELLBROOK
Mailing Address - State:OH
Mailing Address - Zip Code:45305-1744
Mailing Address - Country:US
Mailing Address - Phone:513-893-8000
Mailing Address - Fax:937-848-9106
Practice Address - Street 1:1755 S ERIE HWY STE A
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-4145
Practice Address - Country:US
Practice Address - Phone:513-893-8000
Practice Address - Fax:513-893-8200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-0042962081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000364512OtherANTHEM BC BS
OH5812470001Medicare NSC
OH000000364512OtherANTHEM BC BS