Provider Demographics
NPI:1255781019
Name:LAKESHORE ANESTHESIA STAFFING LLC
Entity type:Organization
Organization Name:LAKESHORE ANESTHESIA STAFFING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GARDINER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:231-225-5216
Mailing Address - Street 1:PO BOX 1296
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46581-1296
Mailing Address - Country:US
Mailing Address - Phone:574-268-9640
Mailing Address - Fax:574-268-0684
Practice Address - Street 1:2848 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3352
Practice Address - Country:US
Practice Address - Phone:269-932-4388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIE8460D367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty