Basic Information
| Provider Information | |||||||||
| NPI: | 1588941066 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKESIDE UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 SAINT JOSEPH DR | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490852529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699833455 | ||||||||
| FaxNumber: | 2699835920 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 SAINT JOSEPH DR | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490852529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699833455 | ||||||||
| FaxNumber: | 2699835920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2011 | ||||||||
| 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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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 4301063125 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.