Provider Demographics
NPI:1548588031
Name:LAKELAND MEDICAL PRACTICES
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT PHYSICIAN PRACTICES
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8127
Mailing Address - Street 1:6416 DEANS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERRIEN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49102-9750
Mailing Address - Country:US
Mailing Address - Phone:269-471-7741
Mailing Address - Fax:269-471-1581
Practice Address - Street 1:2002 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4074
Practice Address - Country:US
Practice Address - Phone:269-687-0200
Practice Address - Fax:269-684-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-10
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1548588031Medicaid
MI1548588031Medicaid