Provider Demographics
NPI:1457359267
Name:CLARKSTON LAKES FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:CLARKSTON LAKES FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLANCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-922-3074
Mailing Address - Street 1:6483 CITATION DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2994
Mailing Address - Country:US
Mailing Address - Phone:248-922-3074
Mailing Address - Fax:248-922-3081
Practice Address - Street 1:6483 CITATION DR
Practice Address - Street 2:SUITE B
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2994
Practice Address - Country:US
Practice Address - Phone:248-922-3074
Practice Address - Fax:248-922-3081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJB067853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080F320090OtherBCN
MI1457359267Medicaid
MICK5028OtherRAILROAD MEDICARE GROUP
MI080F320090OtherBCBS
MI080F320090OtherBCN