Provider Demographics
NPI:1508930512
Name:STANLEY J. ANTOLAK JR. MD PA
Entity Type:Organization
Organization Name:STANLEY J. ANTOLAK JR. MD PA
Other - Org Name:CENTER FOR UROLOGIC AND PELVIC PAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANTOLAK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:651-735-9355
Mailing Address - Street 1:8650 HUDSON BLVD N
Mailing Address - Street 2:SUITE 325
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-9747
Mailing Address - Country:US
Mailing Address - Phone:651-735-9355
Mailing Address - Fax:651-735-0726
Practice Address - Street 1:8650 HUDSON BLVD N
Practice Address - Street 2:SUITE 325
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9747
Practice Address - Country:US
Practice Address - Phone:651-735-9355
Practice Address - Fax:651-735-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16329174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03421Medicare ID - Type UnspecifiedGROUP ID
MNA95365Medicare UPIN