Provider Demographics
NPI:1134472244
Name:LAKE MI MOBILE DOCTORS PC
Entity Type:Organization
Organization Name:LAKE MI MOBILE DOCTORS PC
Other - Org Name:MOBILE DOCTORS OF SAN ANTONIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF QUALITY ASSURANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:TYSYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-751-7200
Mailing Address - Street 1:3319 N. ELSTON AVE.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5811
Mailing Address - Country:US
Mailing Address - Phone:773-751-7200
Mailing Address - Fax:773-583-4401
Practice Address - Street 1:3201 CHERRY RIDGE ST
Practice Address - Street 2:SUITE C-315
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-4823
Practice Address - Country:US
Practice Address - Phone:210-319-5487
Practice Address - Fax:210-342-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicare PIN