Provider Demographics
NPI:1508936311
Name:LAKESHORE MAMMOGRAPHY CENTER PC
Entity Type:Organization
Organization Name:LAKESHORE MAMMOGRAPHY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-228-8000
Mailing Address - Street 1:39200 GARFIELD RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-4095
Mailing Address - Country:US
Mailing Address - Phone:586-228-8000
Mailing Address - Fax:586-228-7870
Practice Address - Street 1:39200 GARFIELD RD
Practice Address - Street 2:SUITE A
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-4095
Practice Address - Country:US
Practice Address - Phone:586-228-8000
Practice Address - Fax:586-228-7870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700Q263820OtherBCBS & BCN
MI104361216Medicaid
MI104341680Medicaid
MI104341680Medicaid
MI700Q263820OtherBCBS & BCN