Basic Information
Provider Information | |||||||||
NPI: | 1194992784 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKELAND PHYSICIAN CARE NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 458 | ||||||||
Address2: |   | ||||||||
City: | NILES | ||||||||
State: | MI | ||||||||
PostalCode: | 491200458 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2696840259 | ||||||||
FaxNumber: | 2696840189 | ||||||||
Practice Location | |||||||||
Address1: | 1234 NAPIER AVE | ||||||||
Address2: |   | ||||||||
City: | SAINT JOSEPH | ||||||||
State: | MI | ||||||||
PostalCode: | 490852112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2696840259 | ||||||||
FaxNumber: | 2696840189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2008 | ||||||||
LastUpdateDate: | 05/13/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MACK | ||||||||
AuthorizedOfficialFirstName: | DENNIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | V.P. OPERATIONS & FACILITY MANAGEME | ||||||||
AuthorizedOfficialTelephone: | 2699838399 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FOUR FLAGS HEALTH VENTURES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.