Provider Demographics
NPI:1811091168
Name:LACINA, SAMUEL J (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:LACINA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 4300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-267-9150
Practice Address - Fax:616-267-1408
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2019-02-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010364892080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A76925Medicare UPIN
MIP18930002Medicare ID - Type Unspecified
MI1373385Medicaid