Basic Information
| Provider Information | |||||||||
| NPI: | 1174918015 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MICHIANA SLEEP & PULMONARY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3904 STONEGATE PARK | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699825864 | ||||||||
| FaxNumber: | 2699825113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3904 STONEGATE PARK | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699825864 | ||||||||
| FaxNumber: | 2699825113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2015 | ||||||||
| LastUpdateDate: | 04/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 2699838624 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
No ID Information.