Provider Demographics
NPI:1245283696
Name:LAKE SHORE PULMONOLOGY, PLC
Entity type:Organization
Organization Name:LAKE SHORE PULMONOLOGY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:IVEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-847-1009
Mailing Address - Street 1:17357 VAN WAGONER RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9702
Mailing Address - Country:US
Mailing Address - Phone:616-847-1009
Mailing Address - Fax:616-847-1607
Practice Address - Street 1:17357 VAN WAGONER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:616-847-1009
Practice Address - Fax:616-847-1607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407127207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P19650Medicare ID - Type Unspecified