Provider Demographics
NPI:1811950447
Name:LAKE OBSTETRICS AND GYNECOLOGY, INC
Entity type:Organization
Organization Name:LAKE OBSTETRICS AND GYNECOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-357-7100
Mailing Address - Street 1:8300 TYLER BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4251
Mailing Address - Country:US
Mailing Address - Phone:440-357-7100
Mailing Address - Fax:440-357-8136
Practice Address - Street 1:8300 TYLER BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4251
Practice Address - Country:US
Practice Address - Phone:440-557-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0890175Medicaid
OH0890175Medicaid