Provider Demographics
NPI:1518020585
Name:HPCN
Entity Type:Organization
Organization Name:HPCN
Other - Org Name:LAKESHORE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE EXECUTIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:231-728-5910
Mailing Address - Street 1:218 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MI
Mailing Address - Zip Code:49455-1028
Mailing Address - Country:US
Mailing Address - Phone:231-861-2187
Mailing Address - Fax:231-894-6248
Practice Address - Street 1:218 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455-1028
Practice Address - Country:US
Practice Address - Phone:231-861-2187
Practice Address - Fax:231-894-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N79630Medicare PIN
MI233916Medicare Oscar/Certification
MI233917Medicare Oscar/Certification