Provider Demographics
NPI:1851430995
Name:LAKE HARBOR INTERNAL MEDICINE ASSOC LLC
Entity Type:Organization
Organization Name:LAKE HARBOR INTERNAL MEDICINE ASSOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:ERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-853-4556
Mailing Address - Street 1:3684 NORTH HARBOR LANE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-6914
Mailing Address - Country:US
Mailing Address - Phone:208-853-4556
Mailing Address - Fax:208-853-5544
Practice Address - Street 1:3684 NORTH HARBOR LANE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-6914
Practice Address - Country:US
Practice Address - Phone:208-853-4556
Practice Address - Fax:208-853-5544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6886207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1377191Medicare ID - Type Unspecified