Provider Demographics
NPI:1295832418
Name:LAKESHORE FAMILY MEDICINE ASSOC PC
Entity type:Organization
Organization Name:LAKESHORE FAMILY MEDICINE ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:K
Authorized Official - Last Name:MACLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:716-947-4851
Mailing Address - Street 1:7060 ERIE RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9306
Mailing Address - Country:US
Mailing Address - Phone:716-947-0408
Mailing Address - Fax:716-947-0413
Practice Address - Street 1:7060 ERIE RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9306
Practice Address - Country:US
Practice Address - Phone:716-947-0408
Practice Address - Fax:716-947-0413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02288315Medicaid
NYAA1216Medicare ID - Type Unspecified