Healthcare Provider Details

I. General information

NPI: 1134254311
Provider Name (Legal Business Name): LAKESIDE CANCER SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 HOLLYWOOD RD SUITE 240
SAINT JOSEPH MI
49085-9151
US

IV. Provider business mailing address

3950 HOLLYWOOD RD SUITE 240
SAINT JOSEPH MI
49085-9151
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-4411
  • Fax: 269-428-4422
Mailing address:
  • Phone: 269-428-4411
  • Fax: 269-428-4422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EDMUND BRIAN PALOYAN
Title or Position: OWNER
Credential: M.D.
Phone: 269-428-4411