Provider Demographics
NPI:1326198102
Name:LAKES REGION UROLOGY, PA
Entity Type:Organization
Organization Name:LAKES REGION UROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PATRISSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-524-8660
Mailing Address - Street 1:85 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246-3113
Mailing Address - Country:US
Mailing Address - Phone:603-524-8660
Mailing Address - Fax:603-528-6220
Practice Address - Street 1:85 SPRING ST
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3113
Practice Address - Country:US
Practice Address - Phone:603-524-8660
Practice Address - Fax:603-528-6220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7001174400000X
NH03021261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH00000655Medicaid
NH1805036Y0NH01OtherANTHEM ASC BILLING ID
NHE57694Medicare UPIN
NH00000655Medicaid