Provider Demographics
NPI:1043211824
Name:LAKE GROVE ENT PC
Entity Type:Organization
Organization Name:LAKE GROVE ENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-699-0370
Mailing Address - Street 1:17704 JEAN WAY
Mailing Address - Street 2:STE 101
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5497
Mailing Address - Country:US
Mailing Address - Phone:503-699-0370
Mailing Address - Fax:971-236-9099
Practice Address - Street 1:17704 JEAN WAY
Practice Address - Street 2:STE 101
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5497
Practice Address - Country:US
Practice Address - Phone:503-699-0370
Practice Address - Fax:971-236-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005809Medicaid
OR135413Medicare PIN
OR134027Medicare PIN
OR134028Medicare PIN
OR005809Medicaid
ORR134026Medicare PIN