1932493863 NPI number — LAKELAND MEDICAL PRACTICES

Table of content: (NPI 1932493863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932493863 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:
Provider Other Organization Name Type Code:
6
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:
1932493863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6416 DEANS HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERRIEN CENTER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49102-9750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-471-7741
Provider Business Mailing Address Fax Number:
269-471-1581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42 N SAINT JOSEPH AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
NILES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49120-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-684-5447
Provider Business Practice Location Address Fax Number:
269-684-0256
Provider Enumeration Date:
06/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CROCKER
Authorized Official First Name:
JANCIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PRACTICE OPERATIONS
Authorized Official Telephone Number:
268-687-1152

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  4301036136 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1538397120 . This is a "GROUP NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MI2051 . This is a "GROUP MEDICARE #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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