Provider Demographics
NPI:1225321045
Name:LAKELAND MEDICAL PRACTICES
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:LAKELAND CANCER SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PRACTICE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-687-1152
Mailing Address - Street 1:3900 HOLLYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9149
Mailing Address - Country:US
Mailing Address - Phone:269-428-4411
Mailing Address - Fax:269-428-4422
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 240
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9159
Practice Address - Country:US
Practice Address - Phone:269-428-4411
Practice Address - Fax:269-428-4422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085395261QX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology