Healthcare Provider Details

I. General information

NPI: 1467732537
Provider Name (Legal Business Name): LAKESHORE COMMUNITY HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 BEVIER ST
SHELBY MI
49455-1239
US

IV. Provider business mailing address

71 BEVIER ST
SHELBY MI
49455-1239
US

V. Phone/Fax

Practice location:
  • Phone: 231-861-2172
  • Fax: 231-861-5100
Mailing address:
  • Phone: 231-861-2172
  • Fax: 231-861-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. COLLEEN JOHNSON
Title or Position: CLINIC MANAGER
Credential: CMPE FABC
Phone: 231-861-2172