Healthcare Provider Details

I. General information

NPI: 1508102633
Provider Name (Legal Business Name): LAKELAND MEDICAL PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 HOLLYWOOD RD SUITE 284
SAINT JOSEPH MI
49085-9159
US

IV. Provider business mailing address

3950 HOLLYWOOD RD SUITE 284
SAINT JOSEPH MI
49085-9159
US

V. Phone/Fax

Practice location:
  • Phone: 269-408-1600
  • Fax: 269-408-1602
Mailing address:
  • Phone: 269-408-1600
  • Fax: 269-408-1602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number4301088693
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateMI

VIII. Authorized Official

Name: WARREN WHITE JR.
Title or Position: VICE PRESIDENT PHYSICIAN PRACTICES
Credential:
Phone: 269-921-4315