Basic Information
| Provider Information | |||||||||
| NPI: | 1336196179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE MICHIGAN NEUROLGICAL SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695561990 | ||||||||
| FaxNumber: | 2695561996 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695561990 | ||||||||
| FaxNumber: | 2695561996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | SIKORSKI | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2695561990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.