Provider Demographics
NPI:1144404724
Name:LAKELAND GENERAL SURGERY
Entity Type:Organization
Organization Name:LAKELAND GENERAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS & FACILITY MANGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8399
Mailing Address - Street 1:60 N SAINT JOSEPH AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2296
Mailing Address - Country:US
Mailing Address - Phone:269-684-6696
Mailing Address - Fax:269-684-5286
Practice Address - Street 1:60 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE E
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2296
Practice Address - Country:US
Practice Address - Phone:269-684-6696
Practice Address - Fax:269-684-5286
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKELAND REGIONAL HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty