Organization
LAKELAND MEDICAL PRACTICES
Active
Other names
Lakeside Urology
Organization subpart
No
Provider details
NPI number
Authorized official
JANCIE CROCKER (DIRECTOR, PRACTICE OPERATIONS)
(268) 687-1152
Entity
Organization
Contact information
Practice address
42 N SAINT JOSEPH AVE, SUITE 200, NILES, MI 49120-2208
(269) 684-5447
(269) 684-0256
Mailing address
6416 DEANS HILL RD, BERRIEN CENTER, MI 49102-9750
(269) 471-7741
(269) 471-1581
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
4301036136
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1538397120
GROUP NPI
MI
01
—
MI2051
GROUP MEDICARE #
MI
Enumeration date
06/08/2011
Last updated
07/13/2012
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