Provider Demographics
NPI:1740457555
Name:LAKE MI MOBILE DOCTORS, P.C.
Entity type:Organization
Organization Name:LAKE MI MOBILE DOCTORS, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, QUALITY ASSURANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:TYSYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-751-7200
Mailing Address - Street 1:3319 N ELSTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5811
Mailing Address - Country:US
Mailing Address - Phone:773-751-7200
Mailing Address - Fax:773-583-4401
Practice Address - Street 1:3388 FOUNDERS RD
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1443
Practice Address - Country:US
Practice Address - Phone:317-471-8701
Practice Address - Fax:317-471-8702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200946960BMedicaid
IN259290Medicare PIN