Basic Information
| Provider Information | |||||||||
| NPI: | 1235562174 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
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| OtherOrganizationName: | BELLANOVA WOMENS HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694298010 | ||||||||
| FaxNumber: | 2694080986 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694298010 | ||||||||
| FaxNumber: | 2694080986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 2699214315 | ||||||||
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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 | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.