Provider Demographics
NPI:1003924739
Name:LAKESHORE INTERNAL MEDICINE AND PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:LAKESHORE INTERNAL MEDICINE AND PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:616-453-6329
Mailing Address - Street 1:437 NORTH 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424
Mailing Address - Country:US
Mailing Address - Phone:616-738-0737
Mailing Address - Fax:
Practice Address - Street 1:437 NORTH 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424
Practice Address - Country:US
Practice Address - Phone:616-738-0737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066494261QM1300X
MI4301074294261QM1300X
MI4301074445261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4193863Medicaid
MI4531728Medicaid
MI4529541Medicaid
MI4531728Medicaid
MI4529541Medicaid
MI0N14150002Medicare ID - Type UnspecifiedDR SCHROTENBOER
MI0N14150004Medicare ID - Type UnspecifiedDR MILLER
MI4193863Medicaid
MI4193863Medicaid