Healthcare Provider Details

I. General information

NPI: 1912105602
Provider Name (Legal Business Name): LAKE REGION MEDICAL CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 04/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8981 GEORGE AVE
BERRIEN SPRINGS MI
49103-1407
US

IV. Provider business mailing address

8981 GEORGE AVE
BERRIEN SPRINGS MI
49103-1407
US

V. Phone/Fax

Practice location:
  • Phone: 269-471-9436
  • Fax:
Mailing address:
  • Phone: 269-471-9436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES ANDREW MOSIMBWA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 269-362-7791