Basic Information
| Provider Information | |||||||||
| NPI: | 1912287467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOORESVILLE PPM LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKESHORE INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 MERIDIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370676325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657000 | ||||||||
| FaxNumber: | 6156286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 157 PROFESSIONAL PARK DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281175605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046623967 | ||||||||
| FaxNumber: | 7046623975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2011 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBOARDING | ||||||||
| AuthorizedOfficialTelephone: | 6154653334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOORESVILLE PPM LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.