NPIMap

Organization Active NPI

Lake ENT Inc

  • Otolaryngology Physician
  • Willoughby, OH
National Provider Identifier
1124235346
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Otolaryngology PhysicianTaxonomy code 207Y00000X
License
054514 Issued in OH
Legal business name
LAKE ENT INC
Practice address
36100 Euclid Ave
#350
Willoughby, OH 44094-4456
Phone
(440) 942-9308
Fax
(440) 942-8981
NPI assigned
May 17, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Khalil Azem, MDNPI 1508859497
Title
President
Phone
(440) 942-9308

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Otolaryngology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Y00000X 054514 OH Primary

Addresses

Primary practice location

36100 Euclid Ave
#350
Willoughby, OH 44094-4456

Mailing address

36100 Euclid Ave
#350
Willoughby, OH 44094-4456
Phone (440) 942-9308

Other identifiers 3

IdentifierTypeStateIssuer
0652575MedicaidOH
351443601003OtherOHMEDICAL MUTUAL
000000131755OtherOHBLUE CROSS BLUE SHIELD

Other names 1

  • Khalil Azem MD Doing business as

National Provider Directory

National Provider Directory

Locations

7215 Center St
Mentor, OH 44060
Phone (216) 444-0226

38459 Lake Shore Blvd
Willoughby, OH 44094
Phone (440) 942-9308

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179360000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1124235346",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "36100 EUCLID AVE",
            "address_2": "#350",
            "city": "WILLOUGHBY",
            "state": "OH",
            "postal_code": "440944456",
            "telephone_number": "440-942-9308",
            "fax_number": "440-942-8981"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "36100 EUCLID AVE",
            "address_2": "#350",
            "city": "WILLOUGHBY",
            "state": "OH",
            "postal_code": "440944456",
            "telephone_number": "440-942-9308",
            "fax_number": "440-942-8981"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE ENT INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-17",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "AZEM",
        "authorized_official_first_name": "KHALIL",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "440-942-9308",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Otolaryngology",
            "state": "OH",
            "license": "054514",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0652575",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL MUTUAL",
            "identifier": "351443601003",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "000000131755",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Khalil Azem MD",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Willoughby, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.