Healthcare Provider Details

I. General information

NPI: 1588941066
Provider Name (Legal Business Name): LAKELAND MEDICAL PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 SAINT JOSEPH DR
SAINT JOSEPH MI
49085-2529
US

IV. Provider business mailing address

815 SAINT JOSEPH DR
SAINT JOSEPH MI
49085-2529
US

V. Phone/Fax

Practice location:
  • Phone: 269-983-3455
  • Fax: 269-983-5920
Mailing address:
  • Phone: 269-983-3455
  • Fax: 269-983-5920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301063125
License Number StateMI

VIII. Authorized Official

Name: WARREN WHITE JR.
Title or Position: VICE PRESIDENT PHYSICIAN PRACTICES
Credential:
Phone: 269-983-8304