Healthcare Provider Details

I. General information

NPI: 1942656749
Provider Name (Legal Business Name): LAKEVIEW MEDICAL & PSYCHIATRIC HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WEST JACKSON STREET SUITE 104
MACOMB IL
61455
US

IV. Provider business mailing address

1601 WEST JACKSON STREET SUITE 104
MACOMB IL
61455
US

V. Phone/Fax

Practice location:
  • Phone: 309-575-3222
  • Fax: 309-404-8000
Mailing address:
  • Phone: 309-575-3222
  • Fax: 309-404-8000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL PAUL BEDNARZ
Title or Position: OWNER
Credential: MD
Phone: 773-485-3222