MEDICARE: LAKE COUNTRY UROLOGY CLINIC, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician

General Provider Information

NPI Number	:	1154453926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE COUNTRY UROLOGY CLINIC, PLLC

Provider Business Mailing Address
First Line	:	17 VINEWOOD AVE
Second Line	:
City	:	STURGIS
State	:	MI
Zip	:	49091-2375
Country	:	US
Telephone Number	:	269-651-4708
Fax Number	:

Provider Business Practice Location Address
First Line	:	235 E CHICAGO ST
Second Line	:
City	:	COLDWATER
State	:	MI
Zip	:	49036-1783
Country	:	US
Telephone Number	:	517-278-4581
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT PLLC
Name	:	MARIANO L ORCA
Credential	:	M.D.
Telephone Number	:	269-651-4708

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	10/17/2007

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