Healthcare Provider Details

I. General information

NPI: 1912322009
Provider Name (Legal Business Name): LAKESHORE SURGICAL CONSULTANTS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 FORT ST SUITE 200
TRENTON MI
48183-4632
US

IV. Provider business mailing address

25432 7TH ST
GROSSE ILE MI
48138-1808
US

V. Phone/Fax

Practice location:
  • Phone: 734-250-0610
  • Fax: 734-676-4407
Mailing address:
  • Phone: 734-250-0610
  • Fax: 734-676-4407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY AMES JR.
Title or Position: TREASURER
Credential:
Phone: 734-250-0610