Provider Demographics
NPI:1033438932
Name:LAKELAND MEDICAL PRACTICES
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:LAKELAND EAR NOSE & THROAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT PHYSICIAN PRACTICES
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8127
Mailing Address - Street 1:42 N SAINT JOSEPH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2203
Mailing Address - Country:US
Mailing Address - Phone:269-687-2910
Mailing Address - Fax:269-687-8770
Practice Address - Street 1:42 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2203
Practice Address - Country:US
Practice Address - Phone:269-687-2910
Practice Address - Fax:269-687-8770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicare PIN