Provider Demographics
NPI:1881666873
Name:LAKES AREA UROLOGY PA
Entity Type:Organization
Organization Name:LAKES AREA UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-828-1418
Mailing Address - Street 1:1903 S 6TH ST
Mailing Address - Street 2:STE 3
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401
Mailing Address - Country:US
Mailing Address - Phone:218-828-1418
Mailing Address - Fax:218-833-8037
Practice Address - Street 1:1903 S 6TH ST
Practice Address - Street 2:STE 3
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401
Practice Address - Country:US
Practice Address - Phone:218-828-1418
Practice Address - Fax:218-833-8037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN739312100Medicaid
C02172Medicare ID - Type Unspecified