Healthcare Provider Details

I. General information

NPI: 1255781019
Provider Name (Legal Business Name): LAKESHORE ANESTHESIA STAFFING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2848 NILES RD
SAINT JOSEPH MI
49085-3352
US

IV. Provider business mailing address

PO BOX 1296
WARSAW IN
46581-1296
US

V. Phone/Fax

Practice location:
  • Phone: 269-932-4388
  • Fax:
Mailing address:
  • Phone: 574-268-9640
  • Fax: 574-268-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberE8460D
License Number StateMI

VIII. Authorized Official

Name: MARCUS A GARDINER
Title or Position: SOLE MBR
Credential: CRNA
Phone: 231-225-5216