Provider Demographics
NPI:1780015008
Name:SOUTH LAKE CLINIC, PA
Entity Type:Organization
Organization Name:SOUTH LAKE CLINIC, PA
Other - Org Name:SOUTH LAKE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHRUP
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:952-401-8300
Mailing Address - Street 1:17705 HUTCHINS DR STE 250
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4103
Mailing Address - Country:US
Mailing Address - Phone:952-401-8300
Mailing Address - Fax:952-401-8240
Practice Address - Street 1:111 HUNDERTMARK RD STE 210
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1196
Practice Address - Country:US
Practice Address - Phone:952-401-8300
Practice Address - Fax:952-401-8243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty