Provider Demographics
NPI:1467732537
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:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE FABC
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:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F41037OtherBCBSM
MIMI2910Medicare PIN