Provider Demographics
NPI:1720364573
Name:LAKELAND MEDICAL PRACTICES
Entity Type:Organization
Organization Name:LAKELAND MEDICAL PRACTICES
Other - Org Name:SLEEP MEDICINE OF LAKELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PRACTICE OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-687-1152
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 1:2500 NILES RD
Practice Address - Street 2:SUITE 9
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3237
Practice Address - Country:US
Practice Address - Phone:269-408-1115
Practice Address - Fax:269-408-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086073207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicare PIN