Basic Information
| Provider Information | |||||||||
| NPI: | 1437362316 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE MICHIGAN SINUS & SLEEP APNEA CENTER, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2680 S. CLEVELAND STREET | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699823368 | ||||||||
| FaxNumber: | 2699833238 | ||||||||
| Practice Location | |||||||||
| Address1: | 2680 S. CLEVELAND STREET | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699823368 | ||||||||
| FaxNumber: | 2699833238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 12/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | FRED | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2699823368 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YS0012X | 4301070920 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4171338 | 05 | MI | MEDICAID |