Basic Information
| Provider Information | |||||||||
| NPI: | 1790982528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESHORE MOBILE M.D., P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 217 | ||||||||
| Address2: | |||||||||
| City: | SAUGATUCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494530217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162837527 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8333 FELCH ST | ||||||||
| Address2: | |||||||||
| City: | ZEELAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494641698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167724644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARCUS | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6162837527 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301050045 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.