Provider Demographics
NPI:1639108863
Name:LAKESHORE ALLERGY PC
Entity Type:Organization
Organization Name:LAKESHORE ALLERGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-738-4262
Mailing Address - Street 1:3290 N WELLNESS
Mailing Address - Street 2:BLDG D STE 180
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424
Mailing Address - Country:US
Mailing Address - Phone:616-738-4262
Mailing Address - Fax:616-738-4266
Practice Address - Street 1:3290 N WELLNESS
Practice Address - Street 2:BLDG D STE 180
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424
Practice Address - Country:US
Practice Address - Phone:616-738-4262
Practice Address - Fax:616-738-4266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051148207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0030084OtherBCBS
P105210OtherBLUECH
MI4604806Medicaid
ON10600Medicare UPIN