Provider Demographics
NPI:1033289269
Name:LAKES REGION SURGICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:LAKES REGION SURGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-528-1547
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04211-1328
Mailing Address - Country:US
Mailing Address - Phone:207-784-9185
Mailing Address - Fax:207-784-1594
Practice Address - Street 1:25 COUNTRY CLUB RD
Practice Address - Street 2:VILLAGE WEST, BUILDING 7
Practice Address - City:GILFORD
Practice Address - State:NH
Practice Address - Zip Code:03249-6972
Practice Address - Country:US
Practice Address - Phone:603-528-1547
Practice Address - Fax:603-524-5536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30009820Medicaid
NHRE4195Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER