Healthcare Provider Details

I. General information

NPI: 1740457555
Provider Name (Legal Business Name): LAKE MI MOBILE DOCTORS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3388 FOUNDERS RD SUITE C
INDIANAPOLIS IN
46268-1443
US

IV. Provider business mailing address

3319 N ELSTON AVE SUITE 200
CHICAGO IL
60618-5811
US

V. Phone/Fax

Practice location:
  • Phone: 317-471-8701
  • Fax: 317-471-8702
Mailing address:
  • Phone: 773-751-7200
  • Fax: 773-583-4401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. TYSYN CONTRERAS
Title or Position: DIRECTOR, QUALITY ASSURANCE
Credential:
Phone: 773-751-7200