Basic Information
| Provider Information | |||||||||
| NPI: | 1346528460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY HEALTH PARTNERS-LAKESHORE, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 674511 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482674511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987139 | ||||||||
| FaxNumber: | 6169759827 | ||||||||
| Practice Location | |||||||||
| Address1: | 72 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494551228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164591560 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2011 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | GILLELAND | ||||||||
| AuthorizedOfficialFirstName: | J. | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6164591560 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.