Basic Information
| Provider Information | |||||||||
| NPI: | 1932493863 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND MEDICAL PRACTICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKESIDE UROLOGY | ||||||||
| 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: | 42 N SAINT JOSEPH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491202208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696845447 | ||||||||
| FaxNumber: | 2696840256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 07/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | CROCKER | ||||||||
| AuthorizedOfficialFirstName: | JANCIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PRACTICE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2686871152 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 4301036136 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1538397120 | 01 | MI | GROUP NPI | OTHER | MI2051 | 01 | MI | GROUP MEDICARE # | OTHER |