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NPI Code Detail

MEDICARE: LAKE MI MOBILE DOCTORS, P.C.

MEDICARE: LAKE MI MOBILE DOCTORS, P.C.
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
1207QG0300XGeriatric Medicine (Family Medicine) Physician
2213E00000XPodiatrist
3207RG0300XGeriatric Medicine (Internal Medicine) Physician

General Provider Information

NPI Number : 1992057566
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKE MI MOBILE DOCTORS, P.C.
Provider Business Mailing Address
First Line : 3319 N ELSTON AVE
Second Line : SUITE 200
City : CHICAGO
State : IL
Zip : 60618-5811
Country : US
Telephone Number : 773-751-7200
Fax Number : 773-583-4401
Provider Business Practice Location Address
First Line : 10016 OFFICE CENTER AVE
Second Line : SUITE 100
City : SAINT LOUIS
State : MO
Zip : 63128-1468
Country : US
Telephone Number : 314-720-0855
Fax Number : 314-735-4335
Authorized Official
Title or Position : DIRECTOR OF QUALITY ASSURANCE
Name : MR. TYSYN CONTRERAS
Credential :
Telephone Number : 773-751-7200
Provider Enumeration Date : 10/08/2012
Last Update Date : 10/08/2012

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Directions to “LAKE MI MOBILE DOCTORS, P.C. ” Practice Location

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