Basic Information
| Provider Information | |||||||||
| NPI: | 1548588031 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6416 DEANS HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERRIEN CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491029750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694717741 | ||||||||
| FaxNumber: | 2694711581 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491204074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696870200 | ||||||||
| FaxNumber: | 2696840199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2010 | ||||||||
| LastUpdateDate: | 04/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 2699838127 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1548588031 | 05 | MI | MEDICAID |