MEDICARE: LAKESHORE MAMMOGRAPHY CENTER PC

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	174400000X	Specialist		MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	700Q263820	OTHER	MI	BCBS & BCN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508936311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESHORE MAMMOGRAPHY CENTER PC

Provider Business Mailing Address
First Line	:	39200 GARFIELD RD
Second Line	:	SUITE A
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-4095
Country	:	US
Telephone Number	:	586-228-8000
Fax Number	:	586-228-7870

Provider Business Practice Location Address
First Line	:	39200 GARFIELD RD
Second Line	:	SUITE A
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-4095
Country	:	US
Telephone Number	:	586-228-8000
Fax Number	:	586-228-7870

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. JUDITH A SUTHERLAND
Credential	:
Telephone Number	:	586-228-8000

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/21/2022

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