Healthcare Provider Details

I. General information

NPI: 1982725735
Provider Name (Legal Business Name): LAKESIDE NEUROLOGY P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28573 SCHOENHERR RD
WARREN MI
48088-4330
US

IV. Provider business mailing address

28573 SCHOENHERR RD
WARREN MI
48088-4330
US

V. Phone/Fax

Practice location:
  • Phone: 586-777-3375
  • Fax: 586-777-3380
Mailing address:
  • Phone: 586-777-3375
  • Fax: 586-777-3380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACEY MARTIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 586-777-3375