1740457555 NPI number — LAKE MI MOBILE DOCTORS, P.C.

Table of content: (NPI 1740457555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740457555 NPI number — LAKE MI MOBILE DOCTORS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE MI MOBILE DOCTORS, 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:
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:
1740457555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3319 N ELSTON AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60618-5811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-751-7200
Provider Business Mailing Address Fax Number:
773-583-4401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3388 FOUNDERS RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46268-1443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-471-8701
Provider Business Practice Location Address Fax Number:
317-471-8702
Provider Enumeration Date:
05/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CONTRERAS
Authorized Official First Name:
TYSYN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, QUALITY ASSURANCE
Authorized Official Telephone Number:
773-751-7200

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200946960B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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