Active NPI
Eric J Lake, DO
- Sports Medicine (Family Medicine) Physician
- Havertown, PA
National Provider Identifier
1710919139
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Sports Medicine (Family Medicine) Physician
- License
- OS012275
- Practice address
- 525 W Chester Pike
Suite 203
Havertown, PA 19083-4500 - Phone
- (610) 789-7767
- Fax
- (610) 789-7768
- NPI assigned
- Jul 7, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Sports Medicine (Family Medicine) Physician | 207QS0010X | OS012275 | PA | Primary |
Addresses
Primary practice location
525 W Chester Pike
Suite 203
Havertown, PA 19083-4500
Mailing address
525 W Chester Pike
Suite 203
Havertown, PA 19083-4500
Phone (610) 789-7767
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1016353100001 | Medicaid | PA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Apr 28, 2021 through Apr 28, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Health Access Network | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Physical Medicine & Rehabilitation Physician
- Chester, PA
- NPI 1356460380
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152230400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1342569600000",
"number": "1710919139",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "525 W CHESTER PIKE",
"address_2": "SUITE 203",
"city": "HAVERTOWN",
"state": "PA",
"postal_code": "190834500",
"telephone_number": "610-789-7767",
"fax_number": "610-789-7768"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "525 W CHESTER PIKE",
"address_2": "SUITE 203",
"city": "HAVERTOWN",
"state": "PA",
"postal_code": "190834500",
"telephone_number": "610-789-7767",
"fax_number": "610-789-7768"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LAKE",
"first_name": "ERIC",
"middle_name": "J",
"name_prefix": "Dr.",
"credential": "DO",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-07",
"last_updated": "2012-07-18",
"status": "A"
},
"taxonomies": [
{
"code": "207QS0010X",
"taxonomy_group": "",
"desc": "Family Medicine, Sports Medicine",
"state": "PA",
"license": "OS012275",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1016353100001",
"state": "PA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Havertown, PA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 18, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.