Provider Demographics
NPI:1811226442
Name:LAKESIDE URGENT CARE, P.C.
Entity Type:Organization
Organization Name:LAKESIDE URGENT CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:LEANNE
Authorized Official - Last Name:STAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-853-2009
Mailing Address - Street 1:44472 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1090
Mailing Address - Country:US
Mailing Address - Phone:586-412-0890
Mailing Address - Fax:586-412-1069
Practice Address - Street 1:44472 HAYES RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1090
Practice Address - Country:US
Practice Address - Phone:586-412-0890
Practice Address - Fax:586-412-1069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1720159304Medicaid
MI700E001600OtherBLUE CARE NETWORK
MI1720159304Medicaid