Provider Demographics
NPI:1528190303
Name:LAKE COUNTRY UROLOGY CLINIC, PLLC
Entity Type:Organization
Organization Name:LAKE COUNTRY UROLOGY CLINIC, PLLC
Other - Org Name:LAKE COUNTRY HEALTH ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, PLLC
Authorized Official - Prefix:
Authorized Official - First Name:MARIANO
Authorized Official - Middle Name:L
Authorized Official - Last Name:ORCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-651-4708
Mailing Address - Street 1:17 VINEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-2375
Mailing Address - Country:US
Mailing Address - Phone:269-651-4708
Mailing Address - Fax:
Practice Address - Street 1:420 W HIGH ST
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-1943
Practice Address - Country:US
Practice Address - Phone:269-651-4708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N96550Medicare PIN