Provider Demographics
NPI:1306819230
Name:LAKE REGION UROLOGY
Entity Type:Organization
Organization Name:LAKE REGION UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HASTINGS
Authorized Official - Last Name:FORESMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-258-5253
Mailing Address - Street 1:192 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-3361
Mailing Address - Country:US
Mailing Address - Phone:315-258-5253
Mailing Address - Fax:315-258-0202
Practice Address - Street 1:192 GENESEE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-3361
Practice Address - Country:US
Practice Address - Phone:315-258-5253
Practice Address - Fax:315-258-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195558302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG67457Medicare UPIN