Healthcare Provider Details

I. General information

NPI: 1770863839
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: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 BEVIER ST
SHELBY MI
49455-1209
US

IV. Provider business mailing address

71 BEVIER ST
SHELBY MI
49455-1209
US

V. Phone/Fax

Practice location:
  • Phone: 231-861-2187
  • Fax: 231-861-5100
Mailing address:
  • Phone: 231-861-2187
  • Fax: 231-861-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. COLLEEN JOHNSON
Title or Position: OFFICE MANGER
Credential: CMPE FABC
Phone: 231-728-5910