Healthcare Provider Details

I. General information

NPI: 1295832418
Provider Name (Legal Business Name): LAKESHORE FAMILY MEDICINE ASSOC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7060 ERIE RD
DERBY NY
14047-9306
US

IV. Provider business mailing address

7060 ERIE RD
DERBY NY
14047-9306
US

V. Phone/Fax

Practice location:
  • Phone: 716-947-0408
  • Fax: 716-947-0413
Mailing address:
  • Phone: 716-947-0408
  • Fax: 716-947-0413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number154802
License Number StateNY

VIII. Authorized Official

Name: CRAIG K MACLEAN
Title or Position: PRESIDENT
Credential: DO
Phone: 716-947-4851