Basic Information
| Provider Information | |||||||||
| NPI: | 1487948311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
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| OtherOrganizationName: | LAKELAND RHEUMATOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | 289 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694080990 | ||||||||
| FaxNumber: | 2694080993 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | 289 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694080990 | ||||||||
| FaxNumber: | 2694080993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 2699838304 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 4301092597 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | MI2051 | 01 | MI | MEDICARE GROUP # | OTHER |