Provider Demographics
NPI:1295820900
Name:LAKESHORE AREA RADIATION ONCOLOGY CENTER
Entity Type:Organization
Organization Name:LAKESHORE AREA RADIATION ONCOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-772-7513
Mailing Address - Street 1:12642 RILEY ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-9202
Mailing Address - Country:US
Mailing Address - Phone:616-355-3876
Mailing Address - Fax:616-786-0255
Practice Address - Street 1:12642 RILEY ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9202
Practice Address - Country:US
Practice Address - Phone:616-355-3876
Practice Address - Fax:616-786-0255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI002827OtherPRIORITY HEALTH
MI32-0-G0-1091-0OtherBCBSM
MI0N84280010Medicare PIN
MI0N84280012Medicare PIN
MI0N84280003Medicare PIN
MI002827OtherPRIORITY HEALTH
MI32-0-G0-1091-0OtherBCBSM
MI0N84280007Medicare PIN
MI0N84280002Medicare PIN
MI0N84280008Medicare PIN
MI0N84280009Medicare PIN
MI0N84280011Medicare PIN