Provider Demographics
NPI:1407902109
Name:LIGHTHOUSE PROFESSIONAL CLINIC, P.C.
Entity Type:Organization
Organization Name:LIGHTHOUSE PROFESSIONAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SEUFERER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-843-8877
Mailing Address - Street 1:409 W LUDINGTON AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2377
Mailing Address - Country:US
Mailing Address - Phone:231-843-8877
Mailing Address - Fax:231-845-0264
Practice Address - Street 1:409 W LUDINGTON AVE STE 307
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2377
Practice Address - Country:US
Practice Address - Phone:231-843-8877
Practice Address - Fax:231-845-0264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI100E310320OtherBLUE CROSS BLUE SHIELD
MI100E361760OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI800E310020OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI800E310020OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0E36176Medicare PIN