Provider Demographics
NPI:1174889604
Name:LAKESHORE COMMUNITY HOSPITAL, INC.
Entity type:Organization
Organization Name:LAKESHORE COMMUNITY HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC REIMBURSEMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:YARA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-873-5675
Mailing Address - Street 1:611 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1190
Mailing Address - Country:US
Mailing Address - Phone:231-873-5675
Mailing Address - Fax:231-873-1825
Practice Address - Street 1:611 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1190
Practice Address - Country:US
Practice Address - Phone:231-873-5675
Practice Address - Fax:231-873-1825
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEATLH PARTNERS LAKESHORE CAMPUS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-10
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAB0335701041C0700X
MIPW011554207Q00000X
MICU005544363A00000X
MIJT003148363A00000X
MIRO009698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3015197Medicaid
0F40011OtherBCBS
MI2963232Medicaid
MI2963232Medicaid