Basic Information
| Provider Information | |||||||||
| NPI: | 1255659744 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHWESTERN MEDICAL CLINIC - BRIDGMAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9625 RED ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | BRIDGMAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491069559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696840259 | ||||||||
| FaxNumber: | 2696840189 | ||||||||
| Practice Location | |||||||||
| Address1: | 9625 RED ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | BRIDGMAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491069559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696840259 | ||||||||
| FaxNumber: | 2696840189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2010 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 2699838304 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.