Lakeshore Health Network
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Provider Relations
Application Form

Name:

Address:

City:

State:

Zip Code:

E-mail Address

Phone:

Pager:

Expected Start Date:

(mm/dd/yyyy)

Good time to call:
   

If you have any questions regarding the application process contact:

>Members Application Process
>Recredentialing Process

Linda Swanson
Phone 231-727-5245
Fax: 231-727-5223 or 5248
Email: lswanson@hackley-health.org

Barb Clark
Phone 231-727-5246
Fax: 231-727-5223
Email: clarkb@trinity-health.org