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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


Home