Provider Demographics
NPI:1669495982
Name:LAKES REGION RADIOLOGY PA
Entity Type:Organization
Organization Name:LAKES REGION RADIOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BRONSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-524-3211
Mailing Address - Street 1:87 SPRING ST
Mailing Address - Street 2:UNIT 101
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246
Mailing Address - Country:US
Mailing Address - Phone:603-524-3211
Mailing Address - Fax:603-524-0089
Practice Address - Street 1:87 SPRING ST
Practice Address - Street 2:UNIT 101
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246
Practice Address - Country:US
Practice Address - Phone:603-524-3211
Practice Address - Fax:603-524-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH41303199Medicaid
NH01Y005437NH01OtherANTHEM
NH=========OtherCIGNA
NHRE0013Medicare ID - Type Unspecified