Basic Information
| Provider Information | |||||||||
| NPI: | 1720364573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
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| OtherOrganizationName: | SLEEP MEDICINE OF LAKELAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 2500 NILES RD | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490853237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694081115 | ||||||||
| FaxNumber: | 2694081166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | CROCKER | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PRACTICE OPERATION | ||||||||
| AuthorizedOfficialTelephone: | 2696871152 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | 4301086073 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
No ID Information.