1720159304 NPI number — LAKESIDE URGENT CARE, P. C.

Table of content: (NPI 1720159304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720159304 NPI number — LAKESIDE URGENT CARE, P. C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE URGENT CARE, P. C.
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:
1720159304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44472 HAYES RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-1090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-412-0890
Provider Business Mailing Address Fax Number:
586-412-1065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44472 HAYES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-1090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-412-0890
Provider Business Practice Location Address Fax Number:
586-412-1065
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEMASHKIEH
Authorized Official First Name:
FADI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
586-412-0890

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ON82490 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1720159304 . This is a "COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700E001600 . This is a "BLUE CARE NETWORK OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1106354161 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1720159304 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700E001600 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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