Healthcare Provider Details

I. General information

NPI: 1710279666
Provider Name (Legal Business Name): LAKE MI MOBILE DOCTORS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 E COMMERCE AVE SUITE 170
KANSAS CITY MO
64120-2171
US

IV. Provider business mailing address

3319 N. ELSTON AVE SUITE 200
CHICAGO IL
60618-5811
US

V. Phone/Fax

Practice location:
  • Phone: 816-994-0073
  • Fax: 816-994-0084
Mailing address:
  • Phone: 773-751-7200
  • Fax: 773-583-4401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. TYSYN CONTRERAS
Title or Position: DIRECTOR OF QUALITY ASSURANCE
Credential:
Phone: 312-939-5090