Provider Demographics
NPI:1508920117
Name:LAKE PLAINS MEDICAL PLLC
Entity Type:Organization
Organization Name:LAKE PLAINS MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MADEJSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-798-3345
Mailing Address - Street 1:100 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:NY
Mailing Address - Zip Code:14103
Mailing Address - Country:US
Mailing Address - Phone:585-798-3345
Mailing Address - Fax:585-798-3416
Practice Address - Street 1:100 OHIO ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103
Practice Address - Country:US
Practice Address - Phone:585-798-3345
Practice Address - Fax:585-798-3416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC0244Medicare ID - Type Unspecified
E42872Medicare UPIN