Provider Demographics
NPI:1407099393
Name:LAKESHORE COMMUNITY HOSPITAL, INC
Entity Type:Organization
Organization Name:LAKESHORE COMMUNITY HOSPITAL, INC
Other - Org Name:SHELBY FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-861-2172
Mailing Address - Street 1:71 BEVIER ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MI
Mailing Address - Zip Code:49455-1239
Mailing Address - Country:US
Mailing Address - Phone:231-861-2172
Mailing Address - Fax:231-861-5100
Practice Address - Street 1:71 BEVIER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455-1239
Practice Address - Country:US
Practice Address - Phone:231-861-2172
Practice Address - Fax:231-861-5100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESHORE COMMUNITY HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-08
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238622Medicare Oscar/Certification