Provider Demographics
NPI:1285924506
Name:LAKESHORE FAMILY CARE, PC
Entity type:Organization
Organization Name:LAKESHORE FAMILY CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:ELMER
Authorized Official - Last Name:ANHALT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-889-7030
Mailing Address - Street 1:72 FILER ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2717
Mailing Address - Country:US
Mailing Address - Phone:231-723-5600
Mailing Address - Fax:231-723-1048
Practice Address - Street 1:3278 LAKE ST
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:MI
Practice Address - Zip Code:49613-5121
Practice Address - Country:US
Practice Address - Phone:231-889-7030
Practice Address - Fax:231-889-7032
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESHORE FAMILY CARE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080E110050OtherBLUE CROSS BLUE SHIELD
MI4612281Medicaid
MI0N22060Medicare PIN
MI080E110050OtherBLUE CROSS BLUE SHIELD