1235863978 NPI number — LAKE MICHIGAN DERMATOLOGY PLLC

Table of content: (NPI 1235863978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235863978 NPI number — LAKE MICHIGAN DERMATOLOGY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE MICHIGAN DERMATOLOGY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235863978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1148 WASHINGTON AVE STE 20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49423-7728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-499-4844
Provider Business Mailing Address Fax Number:
269-849-8708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1148 WASHINGTON AVE STE 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49423-7728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-499-4844
Provider Business Practice Location Address Fax Number:
616-499-4847
Provider Enumeration Date:
07/10/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BERGER
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, OWNER
Authorized Official Telephone Number:
616-499-4844

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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