Healthcare Provider Details

I. General information

NPI: 1174889604
Provider Name (Legal Business Name): LAKESHORE COMMUNITY HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E MAIN ST
HART MI
49420-1190
US

IV. Provider business mailing address

611 E MAIN ST
HART MI
49420-1190
US

V. Phone/Fax

Practice location:
  • Phone: 231-873-5675
  • Fax: 231-873-1825
Mailing address:
  • Phone: 231-873-5675
  • Fax: 231-873-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberAB033570
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPW011554
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberCU005544
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberJT003148
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRO009698
License Number StateMI

VIII. Authorized Official

Name: YARA VILLANUEVA
Title or Position: CLINIC REIMBURSEMENT COORDINATOR
Credential:
Phone: 231-873-5675