Provider Demographics
NPI:1376568378
Name:LAKE NORMAN HEMATOLOGY ONCOLOGY SPECIALISTS, PA
Entity Type:Organization
Organization Name:LAKE NORMAN HEMATOLOGY ONCOLOGY SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUMDIECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-799-3946
Mailing Address - Street 1:170 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8540
Mailing Address - Country:US
Mailing Address - Phone:704-799-3946
Mailing Address - Fax:704-799-3956
Practice Address - Street 1:170 MEDICAL PARK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8540
Practice Address - Country:US
Practice Address - Phone:704-799-3946
Practice Address - Fax:704-799-3956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701019174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCE20805Medicare UPIN
I37030Medicare UPIN
NCH16149Medicare UPIN
NC2280628CMedicare ID - Type UnspecifiedEAGLE, DAVID A
NC2245302DMedicare ID - Type UnspecifiedKRUMDIECK, RICHARD