1538397120 NPI number — LAKELAND MEDICAL PRACTICES

Table of content: (NPI 1538397120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538397120 NPI number — LAKELAND MEDICAL PRACTICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKELAND MEDICAL PRACTICES
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:
COREWELL HEALTH MEDICAL GROUP SOUTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538397120
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 708
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49085-0708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-428-5007
Provider Business Mailing Address Fax Number:
269-428-2789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 NAPIER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-428-5007
Provider Business Practice Location Address Fax Number:
269-428-2789
Provider Enumeration Date:
06/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
WARREN
Authorized Official Middle Name:
Authorized Official Title or Position:
V.P. LAKELAND PHYSICIAN PRACTICES
Authorized Official Telephone Number:
269-983-8127

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OA10085 . This is a "CLINICAL PSYCHOLIGIST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OA10080 . This is a "NURSE MIDWIFE - BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1538397120 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0A10021 . This is a "BLUE CROSS GROUP #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OA10065 . This is a "BCBS - NURSE PRACTIONER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OA10143 . This is a "AUDIOLOGIST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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