Provider Demographics
NPI:1851612329
Name:LAKE MI MOBILE DOCTORS, P.C.
Entity Type:Organization
Organization Name:LAKE MI MOBILE DOCTORS, P.C.
Other - Org Name:MOBILE DOCTORS OF PHOENIX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, QUALITY ASSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:TYSYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-751-7200
Mailing Address - Street 1:3319 N ELSTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5811
Mailing Address - Country:US
Mailing Address - Phone:773-751-7200
Mailing Address - Fax:773-583-4401
Practice Address - Street 1:2345 E. THOMAS RD
Practice Address - Street 2:SUITE # 420
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-955-5700
Practice Address - Fax:602-955-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-18
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ574693Medicaid
AZ574693Medicaid