Provider Demographics
NPI:1457527723
Name:LAKE MI ENT PLLC
Entity Type:Organization
Organization Name:LAKE MI ENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RADTKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-722-4904
Mailing Address - Street 1:1675 LEAHY ST STE 201A
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5542
Mailing Address - Country:US
Mailing Address - Phone:231-722-4904
Mailing Address - Fax:231-722-4804
Practice Address - Street 1:1675 LEAHY ST STE 201A
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5542
Practice Address - Country:US
Practice Address - Phone:231-722-4904
Practice Address - Fax:231-722-4804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI904711539Medicaid