Provider Demographics
NPI:1285950162
Name:LAKEVIEW MEDICAL CENTER PC
Entity type:Organization
Organization Name:LAKEVIEW MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAGDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WANIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-585-2570
Mailing Address - Street 1:23600 HARPER AVE
Mailing Address - Street 2:STE. 103
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1445
Mailing Address - Country:US
Mailing Address - Phone:586-585-2570
Mailing Address - Fax:586-585-2574
Practice Address - Street 1:23600 HARPER AVE
Practice Address - Street 2:STE. 103
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1445
Practice Address - Country:US
Practice Address - Phone:586-585-2570
Practice Address - Fax:586-585-2574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
110500795-2OtherBCBS
MI4243830Medicaid
912517500OtherMEDICAID FLORIDA
P105025OtherBCN
127679OtherCARE CHOICES
21969OtherHEALTH PLAN OF MICHIGAN
P00051536OtherMEDICARE RR
7189170OtherAETNA
G89641OtherHAP
G89641OtherHAP
110500795-2OtherBCBS