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General NPI Number Information
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NPI Number | 1295832418
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Entity Type | Organization
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Legal Business Name | LAKESHORE FAMILY MEDICINE ASSOC PC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 07/30/2008
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Provider Practice Location Address
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Address Line | 7060 ERIE RD
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City | DERBY
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State | NY
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Zip | 14047-9306
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Country | US
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Telephone | 716-947-0408
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Fax | 716-947-0413
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Provider Business Mailing Address
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Address Line | 7060 ERIE RD
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City | DERBY
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State | NY
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Zip | 14047-9306
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Country | US
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Telephone | 716-947-0408
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Fax | 716-947-0413
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Authorized Official
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Title or Position | PRESIDENT
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Name | CRAIG K MACLEAN
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Credential | DO
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Telephone | 716-947-4851
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 154802
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License Number State | NY
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