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General NPI Number Information
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NPI Number | 1013973585
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Entity Type | Organization
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Legal Business Name | LAKESHORE SURGICAL ASSOCIATES PC
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Dates
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Enumeration Date | 04/25/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 577 MICHIGAN AVE SUITE 202
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City | HOLLAND
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State | MI
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Zip | 49423-4911
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Country | US
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Telephone | 616-394-0673
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Fax | 616-394-9825
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Provider Business Mailing Address
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Address Line | 577 MICHIGAN AVE SUITE 202
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City | HOLLAND
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State | MI
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Zip | 49423-4911
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Country | US
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Telephone | 616-394-0673
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Fax | 616-394-9825
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Authorized Official
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Title or Position | PRESIDENT/PHYSICIAN
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Name | DANIEL J DECOOK
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Credential | MD
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Telephone | 616-394-0673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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