Provider Demographics
NPI:1467454199
Name:LAKE SUPERIOR STATE UNIVERSITY
Entity type:Organization
Organization Name:LAKE SUPERIOR STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT STUDENT AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PERESS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:906-635-2634
Mailing Address - Street 1:650 W EASTERDAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1656
Mailing Address - Country:US
Mailing Address - Phone:906-635-2110
Mailing Address - Fax:
Practice Address - Street 1:650 W EASTERDAY AVE
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1656
Practice Address - Country:US
Practice Address - Phone:906-635-2110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P11440Medicare PIN