Healthcare Provider Details

I. General information

NPI: 1144404724
Provider Name (Legal Business Name): LAKELAND GENERAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 N SAINT JOSEPH AVE SUITE E
NILES MI
49120-2296
US

IV. Provider business mailing address

60 N SAINT JOSEPH AVE SUITE E
NILES MI
49120-2296
US

V. Phone/Fax

Practice location:
  • Phone: 269-684-6696
  • Fax: 269-684-5286
Mailing address:
  • Phone: 269-684-6696
  • Fax: 269-684-5286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DENNIS MACK
Title or Position: VP OPERATIONS & FACILITY MANGEMENT
Credential:
Phone: 269-983-8399