Basic Information
| Provider Information | |||||||||
| NPI: | 1821292616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E. MAPLE RD. | ||||||||
| Address2: | SUITE 400-CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132710430 | ||||||||
| FaxNumber: | 3134297941 | ||||||||
| Practice Location | |||||||||
| Address1: | 18100 OAKWOOD BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481244085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132710430 | ||||||||
| FaxNumber: | 3134297941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 01065967A | IN | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 4301098339 | MI | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | BP2-0018119 | 01 | INSTITUTIONAL PERMIT | OTHER |