Provider Demographics
NPI:1699814897
Name:LAKESHORE MEDICAL CENTER
Entity type:Organization
Organization Name:LAKESHORE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:231-728-5910
Mailing Address - Street 1:905 E COLBY ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-1262
Mailing Address - Country:US
Mailing Address - Phone:231-728-5910
Mailing Address - Fax:231-728-5918
Practice Address - Street 1:905 E COLBY ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1262
Practice Address - Country:US
Practice Address - Phone:231-728-5910
Practice Address - Fax:231-728-5918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION79630Medicare ID - Type Unspecified