Provider Demographics
NPI:1912209883
Name:DR. MIKE & FRIENDS PEDIATRICS PC
Entity Type:Organization
Organization Name:DR. MIKE & FRIENDS PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:LANZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-267-2020
Mailing Address - Street 1:1925 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2040
Mailing Address - Country:US
Mailing Address - Phone:541-267-2020
Mailing Address - Fax:541-267-0123
Practice Address - Street 1:1925 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2040
Practice Address - Country:US
Practice Address - Phone:541-267-2020
Practice Address - Fax:541-267-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227196Medicaid