Provider Demographics
NPI:1770863839
Name:LAKESHORE COMMUNITY HOSPITAL INC
Entity Type:Organization
Organization Name:LAKESHORE COMMUNITY HOSPITAL INC
Other - Org Name:LAKESHORE MEDICAL CENTER SHELBY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE FABC
Authorized Official - Phone:231-728-5910
Mailing Address - Street 1:71 BEVIER ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MI
Mailing Address - Zip Code:49455-1209
Mailing Address - Country:US
Mailing Address - Phone:231-861-2187
Mailing Address - Fax:231-861-5100
Practice Address - Street 1:71 BEVIER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455-1209
Practice Address - Country:US
Practice Address - Phone:231-861-2187
Practice Address - Fax:231-861-5100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESHORE COMMUNITY HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-22
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3339Medicare PIN