Healthcare Provider Details

I. General information

NPI: 1720364573
Provider Name (Legal Business Name): LAKELAND MEDICAL PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NILES RD SUITE 9
SAINT JOSEPH MI
49085-3237
US

IV. Provider business mailing address

6416 DEANS HILL RD
BERRIEN CENTER MI
49102-9750
US

V. Phone/Fax

Practice location:
  • Phone: 269-408-1115
  • Fax: 269-408-1166
Mailing address:
  • Phone: 269-471-7741
  • Fax: 269-471-1581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number4301086073
License Number StateMI

VIII. Authorized Official

Name: JANICE CROCKER
Title or Position: DIRECTOR PRACTICE OPERATION
Credential:
Phone: 269-687-1152