Provider Demographics
NPI:1417324393
Name:LAKELAND MEDICAL PRACTICES
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:STONEGATE PLACTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8304
Mailing Address - Street 1:3901 STONEGATE PARK
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9137
Mailing Address - Country:US
Mailing Address - Phone:269-556-6000
Mailing Address - Fax:269-556-6020
Practice Address - Street 1:3901 STONEGATE PARK
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9137
Practice Address - Country:US
Practice Address - Phone:269-556-6000
Practice Address - Fax:269-556-6020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010569802086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicare PIN