Provider Demographics
NPI:1275872509
Name:LAKESHORE UROLOGY PLC
Entity Type:Organization
Organization Name:LAKESHORE UROLOGY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:J
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-604-8363
Mailing Address - Street 1:1445 SHELDON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2480
Mailing Address - Country:US
Mailing Address - Phone:616-604-8363
Mailing Address - Fax:616-604-8364
Practice Address - Street 1:1445 SHELDON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2480
Practice Address - Country:US
Practice Address - Phone:616-604-8363
Practice Address - Fax:616-604-8364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048869208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101995044Medicaid
MI101995044Medicaid