Provider Demographics
NPI:1598746919
Name:LAKESHORE DIAGNOSTICS ULTRASOUND CO.
Entity Type:Organization
Organization Name:LAKESHORE DIAGNOSTICS ULTRASOUND CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-892-8444
Mailing Address - Street 1:1003 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1234
Mailing Address - Country:US
Mailing Address - Phone:989-892-8444
Mailing Address - Fax:989-892-7455
Practice Address - Street 1:1003 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-1234
Practice Address - Country:US
Practice Address - Phone:989-892-8444
Practice Address - Fax:989-892-7455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3012847Medicaid
MI113012847Medicaid
MO718550205Medicaid
MI4997089Medicaid
MI104997089Medicaid
MI310Z910630OtherBLUE CROSS UPIN
MI3012847Medicaid
MI310Z910630OtherBLUE CROSS UPIN
MI104997089Medicaid