Provider Demographics
NPI:1770696379
Name:LAKEHSORE OTOLARYNGOLOGY
Entity type:Organization
Organization Name:LAKEHSORE OTOLARYNGOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:S
Authorized Official - Last Name:VANDERVEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-393-2190
Mailing Address - Street 1:577 MICHIGAN AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423
Mailing Address - Country:US
Mailing Address - Phone:616-393-2190
Mailing Address - Fax:616-393-0147
Practice Address - Street 1:577 MICHIGAN AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423
Practice Address - Country:US
Practice Address - Phone:616-393-2190
Practice Address - Fax:616-393-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty