Provider Demographics
NPI:1932238052
Name:LAKESHORE OSTEOPATHIC CENTER,P.C.
Entity Type:Organization
Organization Name:LAKESHORE OSTEOPATHIC CENTER,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-882-8070
Mailing Address - Street 1:20867 MACK AVE
Mailing Address - Street 2:STE 7
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1392
Mailing Address - Country:US
Mailing Address - Phone:313-882-8070
Mailing Address - Fax:313-882-8413
Practice Address - Street 1:20867 MACK AVE
Practice Address - Street 2:STE 7
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1392
Practice Address - Country:US
Practice Address - Phone:313-882-8070
Practice Address - Fax:313-882-8413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITH015883204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P07700Medicare PIN
MIG35906Medicare UPIN