Healthcare Provider Details

I. General information

NPI: 1134943020
Provider Name (Legal Business Name): LAKELAND MEDICAL PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 W MAIN ST
BENTON HARBOR MI
49022-3607
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 269-408-2258
  • Fax:
Mailing address:
  • Phone: 616-486-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RYAN CATIGNANI
Title or Position: VP PROVIDER SERVICES
Credential:
Phone: 616-486-6790