Provider Demographics
NPI:1013973585
Name:LAKESHORE SURGICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:LAKESHORE SURGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DECOOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-394-0673
Mailing Address - Street 1:577 MICHIGAN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4911
Mailing Address - Country:US
Mailing Address - Phone:616-394-0673
Mailing Address - Fax:616-394-9825
Practice Address - Street 1:577 MICHIGAN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4911
Practice Address - Country:US
Practice Address - Phone:616-394-0673
Practice Address - Fax:616-394-9825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherCOMMERCIAL