Organization
LAKE SURGICAL ASSOCIATES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RUSSELL W PELLAR M.D. (DOCTOR)
(219) 922-0222
Entity
Organization
Contact information
Practice address
10110 DONALD POWERS DR., STE. 202, MUNSTER, IN 46321
(219) 922-0222
(219) 922-8899
Mailing address
10110 DONALD POWERS DR., STE. 202, MUNSTER, IN 46321
(219) 922-0222
(219) 922-8899
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
—
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
90001007
BLUE SHIELD IL
IL
01
—
CH5506
RRMEDICARE
IN
Enumeration date
02/06/2007
Last updated
03/19/2008
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