MEDICARE: LAKE SHORE PULMONOLOGY, PLC

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	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	4301407127	MI
2	207RS0012X	Sleep Medicine (Internal Medicine) Physician	4301407127	MI
3	207RP1001X	Pulmonary Disease Physician	4301407127	MI

General Provider Information

NPI Number	:	1245283696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SHORE PULMONOLOGY, PLC

Provider Business Mailing Address
First Line	:	17357 VAN WAGONER RD
Second Line	:	SUITE 2
City	:	SPRING LAKE
State	:	MI
Zip	:	49456-9702
Country	:	US
Telephone Number	:	616-847-1009
Fax Number	:	616-847-1607

Provider Business Practice Location Address
First Line	:	17357 VAN WAGONER RD
Second Line	:	SUITE 2
City	:	SPRING LAKE
State	:	MI
Zip	:	49456-9702
Country	:	US
Telephone Number	:	616-847-1009
Fax Number	:	616-847-1607

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	MARK JAMES IVEY
Credential	:	M.D.
Telephone Number	:	616-847-1009

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	04/08/2010

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