Provider Demographics
NPI:1548570062
Name:LAKES OBGYN SPECIALIST
Entity Type:Organization
Organization Name:LAKES OBGYN SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-672-2120
Mailing Address - Street 1:PO BOX 776982
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:800-494-5797
Mailing Address - Fax:
Practice Address - Street 1:6401 PRAIRIE ST STE 2100
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-7842
Practice Address - Country:US
Practice Address - Phone:231-672-7939
Practice Address - Fax:231-727-7935
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-18
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty