Basic Information
| Provider Information | |||||||||
| NPI: | 1194737478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LALKA | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | GARY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601067 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043558188 | ||||||||
| FaxNumber: | 7043558192 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172057481 | ||||||||
| FaxNumber: | 3138761305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2005-01060 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 01035930A | IN | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 2005-01060 | NC | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 01035930A | IN | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 4301500422 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | N0106A | 05 | SC | MEDICAID | P00245249 | 01 | RAILROAD MEDICARE | OTHER | 1396N | 01 | NC | BCBS | OTHER | 1194737478 | 05 | NC | MEDICAID | 5901224 | 05 | NC | MEDICAID |