1134254311 NPI number — LAKESIDE CANCER SPECIALISTS, PLLC

Table of content: (NPI 1134254311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134254311 NPI number — LAKESIDE CANCER SPECIALISTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE CANCER SPECIALISTS, 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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134254311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3950 HOLLYWOOD RD
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49085-9151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-428-4411
Provider Business Mailing Address Fax Number:
269-428-4422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 HOLLYWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085-9151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-428-4411
Provider Business Practice Location Address Fax Number:
269-428-4422
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PALOYAN
Authorized Official First Name:
EDMUND
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-428-4411

Provider Taxonomy Codes

  • Taxonomy code: 261QX0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0P42500 . This is a "MEDICARE ID" identifier . This identifiers is of the category "OTHER".




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