Basic Information
| Provider Information | |||||||||
| NPI: | 1467732537 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESHORE COMMUNITY HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHELBY FAMILY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 BEVIER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494551239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318612172 | ||||||||
| FaxNumber: | 2318615100 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 BEVIER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494551239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318612172 | ||||||||
| FaxNumber: | 2318615100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2011 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | COLLEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2318612172 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKESHORE COMMUNITY HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CMPE FABC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0F41037 | 01 | MI | BCBSM | OTHER |