Provider Demographics
NPI:1417493545
Name:LAKELAND MEDICAL PRACTICES
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:LAKELAND GENERAL SURGERY SJ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF PHYSICIAN PRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8127
Mailing Address - Street 1:2990 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8607
Mailing Address - Country:US
Mailing Address - Phone:269-983-3368
Mailing Address - Fax:
Practice Address - Street 1:2990 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8607
Practice Address - Country:US
Practice Address - Phone:269-983-3368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406148261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicare PIN