Provider Demographics
NPI:1053696997
Name:LAKE ERIE MEDICAL GROUP PC
Entity type:Organization
Organization Name:LAKE ERIE MEDICAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-452-5772
Mailing Address - Street 1:2501 W 12TH ST STE C10
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4527
Mailing Address - Country:US
Mailing Address - Phone:814-580-5600
Mailing Address - Fax:814-455-2584
Practice Address - Street 1:2501 W 12TH ST STE C10
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4527
Practice Address - Country:US
Practice Address - Phone:814-580-5600
Practice Address - Fax:814-455-2584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1053696997OtherUNITED HEALTHCARE
PA1053696997OtherHEALTH AMERICA
PA1053696997OtherUPMC HEALTH PLAN
PA102674949Medicaid
PA7198943OtherCIGNA
PA2669985OtherHIGHMARK BCBS
PA235369Medicare PIN