Basic Information
| Provider Information | |||||||||
| NPI: | 1275852162 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKELAND NEUROSURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695561990 | ||||||||
| FaxNumber: | 2695561996 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695561990 | ||||||||
| FaxNumber: | 2695561996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2010 | ||||||||
| LastUpdateDate: | 03/09/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2699838507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.