Provider Demographics
NPI:1982677548
Name:LAKELAND IMMEDIATE CARE CENTER
Entity Type:Organization
Organization Name:LAKELAND IMMEDIATE CARE CENTER
Other - Org Name:CASSOPOLIS FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:GEEGAN
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-445-3874
Mailing Address - Street 1:261 M 62
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-1034
Mailing Address - Country:US
Mailing Address - Phone:269-445-3874
Mailing Address - Fax:269-445-2076
Practice Address - Street 1:261 M 62
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-1034
Practice Address - Country:US
Practice Address - Phone:269-445-3874
Practice Address - Fax:269-445-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT080A46198OtherBCBS
MI2890350Medicaid
MIA46198004Medicare PIN
MI2890350Medicaid
MI231906Medicare Oscar/Certification