Provider Demographics
NPI:1699043299
Name:LAKESHORE SPINE AND PAIN PC
Entity Type:Organization
Organization Name:LAKESHORE SPINE AND PAIN PC
Other - Org Name:ACCESSIBLE URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKWANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-843-1553
Mailing Address - Street 1:5511 W US HIGHWAY 10
Mailing Address - Street 2:SUITE B
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5511 W US HIGHWAY 10
Practice Address - Street 2:SUITE B
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2455
Practice Address - Country:US
Practice Address - Phone:231-843-1553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23-8920Medicare PIN
MI238919Medicare PIN