Provider Demographics
NPI:1821201500
Name:LAKE MICHIGAN NEPHROLOGY, L.L.C
Entity Type:Organization
Organization Name:LAKE MICHIGAN NEPHROLOGY, L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BRASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-428-0819
Mailing Address - Street 1:3800 HOLLYWOOD RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8510
Mailing Address - Country:US
Mailing Address - Phone:269-428-0819
Mailing Address - Fax:269-428-0841
Practice Address - Street 1:3800 HOLLYWOOD RD STE 104
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8511
Practice Address - Country:US
Practice Address - Phone:269-428-0819
Practice Address - Fax:269-428-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079804174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N27670Medicare ID - Type Unspecified